*EW  FINDINGS 
'HTHALMOLOGY 
AND  OTOLOGY 


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BERKELEY 

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UNIVERSITY  OF 
CALIFORNIA 


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THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 


GIVEN  WITH  LOVE  TO  THE 

OPTOMETRY  LIBRARY 

BY 

MONROE  J.  HIRSCH,  O.D.,  Ph.D. 


NEW  FINDINGS 

IN  OPHTHALMOLOGY 

AND  OTOLOGY 


A  MONOGRAPH. 


WITH  A  DESCRIPTION  OF  TWO  NEW  INSTRUMENTS. 


ILLUSTRATED. 


SECOND  EDITION. 

By 
E.  H.  HAZEN,  M.  D. 

Lecturer   on    Ophthalmology   and   Otology    Medical   Department   State 
University  from   1870  to   1874.     Emeritus  Professor  of  Ophthal- 
mology    and   Otology,    College   of   Physicians    and   Surgeons, 
Medical  Department  of  Drake   University,   Des   Moine 
IoiL-a.     Member  of  the  American  Medical  Associa- 
tion,   Iozva    State    Medical    Society.     Et  , 


OPTOMETRY 


COPYRIGHTED  1911 

By 

E.  H.  HAZEN,  M.  D., 

Des  Moines. 


PREFACE. 


Rt  is 

HI/ 

or 


He  who  essays  to  write  a  book  in  these  times,  should 
have  a  reason. 

The  incentives  to  authorship  may  be  various — -a  desire 
to  exercise  a  talent  in  expressing  thoughts  already  pro- 
mulgated by  others;  a  desire  for  recognition  in  his  own 
field  of  work;  or  a  desire  to  make  known  the  result  of  his 
labor  in  original  investigation. 

These  are  all  legitimate  motives,  and  the  merits  of  his 
labor  are  always  tested  by  the  life  of  the  book. 

It  is  not  my  purpose  to  write  a  Text  book,  but  a  Mono- 
graph of  the  subject  of  the  treatment  of  the  Muscles  of 
the  Eye. 

It  is  particularly  gratifying,  to  be  enabled,  as  I  think, 
to  contribute  to  the  profession,  some  improvement  in 
the  science  of  Ophthalmology,  in  which  I  have  spent 
the  most  of  a  long  life. 

I  take  the  liberty  of  dissertating,  in  the  introduction, 
on  some  of  the  late  movements,  in  the  handling  of  a  class 
of  cases,  to  which  I  contribute  my  method  of  treatment. 

I  have  presented  the  history  of  this  subject  and  the 
views  of  writers  down  to  the  present  time,  in  excerpts 
from  the  authors,  instead  of  appropriating  their  thoughts, 
and  expressing  them  in  my  own  words.  I  hope  1  have 
done  no  violence  to  these  writings. 

I  believe  that  the  means.  I  have  devised  for  the  testing 
of  the  muscles,  not  only  add  to  the  good  management  of 
those  cases  already  recognized  as  having  muscular 
troubles,  but  they  include  relief  for  a  large  percentage, 
which  are  now  supposed  to  be  outside  the  work  of  the 
Ophthalmologist. 


INTRODUCTION. 


A  great  division  in  the  world's  work  is  the  combatting 
of  disease.  While  the  forces  of  nature  are  constantly 
propelling  toward  the  higher  and  better  samples  of  im- 
provement, there  is  an  antagonizing  force  which  dete- 
riorates this  impulse.  The  first  we  call  good  and  the  second 
evil. 

The  mind  of  man  attempts  to  grapple  with  the  problem 
and  abets,  aids,  directs  and  cultivates  the  one  and  prunes, 
hunts,  cuts  off  and  destroys  the  other.  It  is  one  of  the 
wonderful  products  of  nature  that  the  mind  of  man, 
which  itself  has  come  up  out  of  nature,  should  tower  over 
nature  and  presume  to  direct  its  growth. 

Nevertheless,  when  we  compare  rude  nature  and  the 
work,  which  man  is  enabled  to  show  as  his,  we  are  puzzled 
to  decide  which  is  the  most  wonderful. 

We  do  not  detract  from  the  Creator  in  admiring,  with 
awe,  the  direction  which  man  has  given  to  the  many 
things  on  which  he  has  put  his  finger,  for  he  is  but  a 
servant  of  nature  and  must  work  by  her  laws  and  in 
contemplating  the  direction  he  has  given  to  nature,  and 
to  that  which  he  has  wrought,  he  but  glorifies  the  maker  of 
himself,  and  the  echo  of  achievement  reverberates  from 
generation  to  generation,  and  man  becomes  more  civilized, 
lives  in  luxury  and  sings  more  praises  to  his  God. 

With  the  enumeration  of  all  the  benefits  of  civilization, 
there  are  elements  of  evil.  The  higher  organization  of 
man  and  that  which  enables  him  to  have  dominion  over 


HAZEN'S   NEW    FINDINGS 

nature  consists  of  the  develop menl  oi  his  nervous  system. 
With  culture  comes  disease.  Many  are  the  examples  in 
nature,  where  impulses  have  proceeded  that  seemed  to 
be  good,  but  have  gone  up  and  on  until  that  very  element 
has  wrought  its  own  destruction. 

'This  development  oi  the  brain  and  nervous  system, 
which  enables  man  to  do  the  work  that  shows  itself  on 
every  hand,  has,  in  the  majority  of  mankind,  refined, 
cultured  and  made  more  powerful  and  strenuous  each 
succeeding  generation,  until  in  our  own,  we  may  estimate 
its  capabilities  as  greater  than  any  that  have  gone  before, 
and  we  may  anticipate  that  in  the  generations  to  come, 
there  will  be  greater  masters  than  in  the  present. 

But  these  advances  are  made  at  a  great  cost;  the  stren- 
uousness,  the  ambitions,  the  requirements  of  the  habits 
of  industry  to  attain  the  coveted  goal  draw  upon  the 
vitality  of  the  nervous  system,  and  the  nature  of  man's 
physical  and  anatomical  system  is  not  prepared  for  the 
demands,  which  he  makes  upon  it.  When  carried  too 
far,  pain  comes  as  a  warning,  and  when  not  heeded  a 
break-down  is  the  consequence  and  death  of  the  unfit 
is  the  result. 

Xo  better  example  can  be  given  of  the  exceedingly 
great  demand  upon  the  civilization  of  the  day  than  that 
made  upon  the  organ  of  vision.  Not  only  is  this  organ 
continuously  and  excessively  exercised  in  acquiring  an 
education  for  the  start  in  life,  but  it  is  upon  this  organ  that 
we  depend  mainly  for  existence  in  the  struggle  of  life, 
and  upon  it  for  the  success  of  the  greater  ambitions 
which  comes  to  the  few. 

The  manual  labor  of  the  generality  of  mankind  is 
becoming  more  and  more  narrowed  down  to  the  need  of 
a  limited  action  of  the  muscles  of  the  eye,  and  but  a  few 
of  the  other  muscles  of  the  body;  the  necessities  of 
many,  indeed  most  of  the  occupations,  require  but  little 
variety  of   motion,   and   this   limited   motion   is   more  ex- 


[NTRODUCTION 

haustive  on  the  nervous  system  than  the  occupations 
of  our  forefathers,  which  usually  called  upon  the  action 
of  the  whole  muscular  system  in  the  performance  of  their 
duties. 

The  consequence  is  that  we  have  a  generation  of  abnor- 
mal hyperaesthenic  nerve  development,  that  is  on  the 
road  to  asylums  and  has  for  its  end  insanity. 

Poor  humanity  resorts  to  alcohol,  narcotics,  opiates 
and  sedatives  to  dull  the  disturbance.  The  require 
ments  of  an  exhausted  nervous  system  demand  an  abnor- 
mal excitement  and  stimulant;  the  already  tired  organ 
of  vision  seeks  amusements  other  than  those  requiring 
further  exercise  of  sight,  and  the  social  enticements  lure 
them,  and  their  environment  is  not  always  the  best,  and 
so  bad  habits  are  acquired,  and  waste  of  time  and  a  lower 
or  indifferent  life  is  the  consequence. 

The  type  of  American  physique  is  a  nervous  organiza- 
tion and  the  attention  of  the  American  physician  is  par- 
ticularly directed  to  this  class  of  disorders. 

From  experience  in  these  affections,  and  contact  with 
others  whom  I  have  been  teaching,  it  is  my  conviction 
that  this  disease  is  the  most  prevalent  one  in  America. 
American  people  read  more  than  any  others.  Her  people 
develop  faster  because  of  those  occupations,  requiring 
near  sight.  Their  ancestors  used  their  eyes  but  little  in 
convergence,  and  therefore  had  not  cultivated  a  physiolog- 
ical  condition  toward  the  necessities  of  the  new 
civilization,  and  had  not  transmitted  them  by 
heredity.  These  people,  thus  wanting  in  the  advantages 
of  heredity,  have  to  cope  with  a  disadvantage,  in  strange 
occupations,  and  are  apt  to  break  down  in  the  race  for 
life  in  the  new  environment. 

The  frequent  appeal  to  the  eye  specialist,  of  those 
with  nervous  systems,  for  relief,  and  the  growing  impor- 
tance of  this  work,  which  the  oculist  has  gradually 
learned,  in  relation  to  the  nervous  diseases,  and  also,  as 


8  HAZEN'S    NEW    FINDINGS 

the  author  believes  that  he  has  a  further  contribution 
in  this  line,  he  takes  the  liberty  df  dissertating  broadly 
upon  the  situation  as  he  sees  it,  hoping  that  his  thoughts 
may  be  considered,  and  weighed  and  turned  out  onto  the 
tide,  that  flows  in  and  out  and  purifies  and  improves  the 
humanitarian's  labors. 

\  i  withstanding  that  the  pathology  of  nervous  troubles 
has  made  some  progress  in  the  profession  as  to  differen- 
tiation, when  presented,  by  sufferers,  to  their  friends, 
the   troubles   are,   as   a   whole,   about   alike   in   character. 

It  makes  a  great  difference  upon  which  road  they  seek 
advice  regarding  them.  If  the  patient  has  been  to  the 
Oculist,  he  emerges  with  a  saddle  and  bridle  on  his  face. 
If  he  is  switched  off  to  the  Nervous  Disease  man,  he  is 
relegated  to  a  Sanatorium  and  put  to  "rest."  If  to  the 
Hydropath,  he  is  massaged,  soaked  and  washed  inside 
and  out.  If  to  the  Faith  cure,  he  is  persuaded,  cajoled  and 
hypnotized.  Neither  Specialist  seems  to  have  know- 
ledge of  any  better  method  of  relief.  Some  of  them  at- 
tempt to  cure  the  symptoms  by  improving  the  general 
health,  and  others  will  take  medicine  and  a  vacation 
to  build  up  the  constitution,  with  the  expectation  that  the 
symptoms  (which  the  physicians  say  are  caused  by 
constitutional  diseases)  will  depart.  Others  claim  that 
the  theories  of  disease  are  a  delusion  and  a  snare. 

Each  specialist  is  trained  to  believe  that  he  is  able 
to  cure  by  his  particular  method.  There  is  not  that 
linking  together  of  methods,  that  one  would  expect  from 
these  men,  who  have  generally  been  educated  in  the  same 
colleges,  and  belong  to  the  same  Medical  societies — 
nevertheless,  the  Specialists  represent  a  different  Tribe 
and  think  on  the  lines  of  the  particular  specialty  of  their 
choice. 

There  is  need  of  a  combination  of  the  knowledge 
attained  in  the  world's  work — unprejudiced,  disinter- 
ested   and    philanthropic    in    its    spirit    to    apportion    its 


INTRODUCTION  9 

application.  The  desirability  of  this  has  been  seen  of 
late,  and  some  of  the  religious  organizations  have  at- 
tempted to  supply  the  necessity  by  a  fusing  of  religion 
and  medicine. 

The  movement  takes  up  a  different  method  of  bene- 
fitting mankind  from  that  heretofore  practiced.  It  is 
a  combination  of  the  institutions  that  have  been  the 
closest  to  the  social  nature  of  man — the  religions  and 
medicine.  The  church,  ostensibly,  has  been  instituted 
to  direct  man  in  attaining  to  the  best  in  this  life  and 
beyond  the  grave,  and,  to  a  certain  extent,  it  has  pro- 
moted a  moral  life,  but  of  late  years  there  has  been  more 
attention  paid  to  matters  of  this  life.  The  church  is  a 
social  institution,  and  more  than  any  other,  looks  after 
the  welfare  of  its  members.  This  mission  is  becoming 
more  and  more  the  work  of  the  church.  There  is  no 
other  institution  that  affords  such  opportunities  to  guard 
and  teach  the  social  and  moral  phases  of  life.  All  com- 
munities need  a  corps  of  intelligent  men  and  women, 
who  will  interest  themselves  in  each  others'  temporal 
welfare  and  attend  to  the  social  up  lift;  associated  with 
them  should  be  the  disinterested  scientific  man,  who 
understands  disease  and  sanitation.  His  education 
should  be  broad — a  graduate  in  medicine — one  who  un- 
derstands, not  only  the  diagnosis  of  disease,  but  sanita- 
tion in  all  its  branches — architecture- — plumbing — land- 
scape gardening — bacteriology  and  chemistry — physical 
culture  etc.,  but  he  should  not  be  a  practitioner  of  medicine. 
This  limit  would  place  him  at  once  before  the  people, 
as  an  unbiased  adviser  and  as  one,  who  would  devote 
his  energy  to  the  combatting  of  the  causes  of  disease. 
The  Science  of  Sanitation  would  grow  in  the  hands  of 
such  a  promoter,  for  he  would  be  an  independent  ad- 
visor in  all  branches. 

The  Minister,  through  his  profession,  enters  into  that 
field   of  labor,   which   gets  closer  to  the   social   aspect   of 


10  HAZEN'S  NEW    FIX  DINGS 

civilization    and    comes    in    contact  with  the  sympathetic 

and  brotherly  nature  of  man,  more  than  any  other. 
His  education  touches  upon  the  finer  and  more  esthetic 
nature  and  reaches  man  through  impulses,  that  we  classify 
as  belonging  to  the  heart.  His  training  of  mind  and 
habits  of  thought  fit  him  better  than  any  other  class  of 
men  to  get  to  and  direct  social  and  domestic  matters. 
\\\>  purposes  and  aspirations  adapt  him  to  win  the  confi- 
dence of  his  fellow  men  who  toil  and  have  not  had  or 
have  not  laid  hold  of  opportunities  to  become  educated 
or  enlightened  in  the  progress  of  the  age. 

These  people  need  the  helping  hand  of  those,  better 
educated,  to  enable  them  to  adjust  themselves  to  modern 
methods  and  thoughts,  and  to  advise  them  where  aid 
can  be  obtained.  \\  ith  the  council  of  the  man,  scien- 
tifically educated,  many  of  the  difficulties  and  troubles, 
on  the  road  to  success,  may  be  made  smooth  and  com- 
fortable. 

Behind  these  two  persons,  who  would  come  directlv  in 
contact  with  the  public,  might  be  a  board  composed  of 
business  and  professional  men,  wrho  would  constitute  a 
financial  council  and  referee.  This  is  not  too  formidable, 
in  the  light  of  what  is  already  organized  in  some  of  the 
churches  of  the  east. 

The  weakness  of  these  organizations  that  have  at- 
tempted this  combination,  is  in  the  association  of  the 
church  with  specialists  of  Nervous  diseases,  and  they 
practitioners  of  medicine. 

The  Advisory  board  would  have  a  distinctive  work 
that  would  be  accepted  as  most  free  from  sinister  motive, 
and  would  be  more  free  from  suspicion  of  graft  than  any 
other  source  from  which  to  get  advice.  It  ought  to  be 
mostly  supported  by  the  benevolent  contributions,  but 
not  wholly,  for  the  best  charities  of  the  day  require  of 
the  person  benefitted,  some  remuneration  for  time  and 
service. 


INTRODUCTION  11 

The  majority  of  the  people  need  the  council  of  the  educa- 
ted, the  experienced,  the  broad-minded,  honest,  true 
philanthropic  friend.  Many  men  and  women,  who  pass 
for  intelligent  people,  place  their  expectations  of  success 
on  a  wrong  basis  for  results.  They  do  not  understand 
the  laws  of  nature  nor  of  society,  and  when  in  trouble, 
or  when  being  carried  away  by  emotion  or  passion,  make 
mistakes  that  wreck  their  lives. 

The  Missionary  spirit  of  the  church  and  the  accumula- 
tion of  moral  ethics,  which  it  has  stored  away,  and  the 
reputation  it  has  for  true  philanthrophy  ought  to  be 
directed  more  to  the  mundane  relations  of  men  and  the 
direction  of  their  purposes — the  building  up  of  the 
physical  man — enlightening  his  mental  and  moral  nature 
— clarifying  society  and  directing  the  rearing  of  the  coming 
generation. 

From  our  experience  in  the  past,  shall  we  not  look  for 
a  scientific  solution  of  all  the  problems  with  which  we 
seek  to  benefit  mankind,  mentally,  morally,  and  physically, 
and  shall  we  not  put  our  faith  in  this  method  to  bring 
about  our  happiness  and  thrift: 

The  Alchemist,  in  former  generations,  with  a  sordid 
motive  it  is  true,  dissipated  a  mystery  and  found  nature's 
well  defined  laws  in  the  atoms,  which  are  so  small  that 
they  have  not  yet  been  seen,  and  the  result  is,  that  the 
beautiful  and  practical  science  of  chemistry  has  been 
established. 

Pathology  groped  its  way  in  superstition  for  ages, 
until  the  Microscopist  increased  the  convexity  of  his 
object  lens  and  immersed  it;  when  the  science  of  Bacteri- 
ology was  instituted  and  sanitation  was  born  again; 
salvation  for  millions  was  guaranteed;  fevers  are  now 
harnessed,  and  climates  are  habilitated,  and  man's  plans 
are  made  possible  when  before  they  failed. 

Accoustics,  as  a  science,  was  a  mystery.  Edison, 
following  the  wave  theory  and  taking  the  pattern  of  the 


12  HAZEN'S   NEW    FINDINGS 

ear,  put  a  needle  into  an  artificial  drum  and  we  record 
the  sounds  in  wax.  The  telephone  is  half  brother  to 
this  and  again  mystery  is  materialized. 

We  have  now,  on  our  hands,  the  theory  of  mind  over 
matter.  Whispers  of  solutions  load  the  printing  presses. 
The  subject  is  so  mysterious  that  superstition  envelopes 
it  as  it  did  other  questions  of  yore,  but  if  it  is  ever  solved, 
science  will  do  it.  But,  some  will  ask.  what  has  this 
to  do  with  eye  strain? 

We  have,  in  this  subject,  phenomena  that  are  wide- 
spread, and  the  syndromes  of  the  particular  groups 
are  so  different  in  manifestation,  and  some  so  remote 
from  the  organ  of  vision,  affecting  the  system  so  differently 
and  implicating  the  mental,  moral  and  physical  nature 
of  man,  so  that  all  the"pathys  and  ologies"take  it  up, 
and  build  into  their  doctrines  an  explanation  of  and  a 
remedy  for  them.  Some  of  the  theories  open  out  a  way 
toward  a  proper  basis  for  their  solution,  and  others  are 
but  stumbling  blocks. 

The  nervous  organization  of  man,  which  has  so  far 
out-reached  that  of  other  species,  becomes  more  and  more 
intricate,  and  most  of  the  troubles  with  which  we  have 
to  deal,  being  symptomatic,  functional  and  phenomenal 
and  so  far  from  our  instruments  of  precision,  that  opinions 
regarding  them  must  necessarily  be  various. 

Many  a  problem  has  been  delayed  in  solution,  because 
of  a  wrong  direction  being  taken  for  its  mastery,  and  at 
last  it  was  conquered  by  a  simple  method. 


EYE  STRAIN  AND  ASTHENOPIA. 


DEFINITIONS  AND  DESCRIPTIONS. 

One  of  the  most  interesting  histories  in  medicine  is 
that  of  the  growth  of,  and  advancement  made  in  the 
understanding  of  the  functional  troubles  of  the  organ 
of  vision.  There  is  no  other  organ  of  the  body  (unless 
it  be  the  brain)  that  is  so  intricate,  subtle  and  so  slow  in 
being  understood. 

We  have  had  in  science,  some  of  the  brightest  ge- 
niuses, who  have  given  us  the  fruits  of  their  labors;  among 
them,  Young,  Helmholtz,  Donders,  Von  Graefe  and  Xoyes, 
who  have  worked  in  this  particular  field  and  others  who 
are  still  alive  and  have  not  finished  their  work.  To 
the  fruits  of  the  labor  of  these  men,  the  world  is  indebted 
for  the  means  by  which  it  is  enabled  to  do  the  work 
which  civilization  and  new  methods  of  labor  have  entailed. 
The}'  have  furnished  the  treatment  that  relieves  a  greater 
number  in  the  realms  of  suffering  humanity,  than  any  of 
the  other  specialists  in  medicine,  and  yet  there  is  room 
for  progress.  The  pendulum  will  swing  from  one  side 
to  the  other  in  the  emphasis  of  theories  and  practices, 
but  it  will  be  in  the  hands  of  men  still  alive,  and  if  they 
have  the  metal  of  those  whom  we  mention  as  having 
died,  ere  another  generation  will  have  passed,  they  too 
will  hand  in  valuable  contributions  and  make  advance- 
ment in  this  beautiful  science. 

Denouncements  and  indifferent  attitudes,  will  always 
be    the    reception    given    by    many,    to    departures    from 


]  I  HAZEN'S   NEW    FINDINGS 

staid  methods  and  authority;  however,  when  the  new 
principles  come  to  men  who  have  courage,  and  who  avow 
them,  there  are  sometimes  those,  who  take  hold  <>t  the 
new  ideas  with  great  avidity  and  enthusiasm,  but,  very 
often  many  o\  them  are  so  imperfectly  demonstrated, 
thai  other  minds  do  not  understand  them  as  the  author 
did  and  hence,  those  attempting  to  practice  them  do 
not  get  the  same  results.  This  truth  cannot  be  better 
illustrated  than  in  the  intricate  physiology  and  pathol- 
•  >t  the  eye.  and  a  single  step  forward  in  this  science 
deserves  attention. 

\\  e  will,  as  far  as  possible,  examine  the  authors  of  the 
day,  regarding  the  main  points  of  the  functions  of  the 
organ  of  vision,  and  endeavor  to  get  at  the  status  of  the 
subject  of  disorders  connected  therewith,  and  as  held 
by  the  profession  at  the  present  time.  We  will  examine 
the  position  taken  by  the  authors  of  our  day,  in  the  order  of 
the  date  of  their  writings.  In  the  examination  of  the 
subject  by  the  inquiries  adopted,  we  can  best  set  forth 
the  development  of  the  science  and  show  the  steps  taken 
therein,  and  thus  be  enabled  the  better  to  compare  them 
with  what  is  here  offered  as  a  new  contribution. 

INQUIRIES. 

1st.  Terms.  Eye  strain,  Asthenopia,  both  ace  emmedative  and  mus 
cular,  as  words  to  encompass  disorders  of  the  function 
of  sight. 

2nd.  The  doctrine  of  Insufficiency  of  the  Muscles. 

3d.     The  Relation  of  Ametropia  to  Muscular  Anomalies. 

4th.  The  Theories  of  Balance  and  Equilibrium  and  the  Relation 
of  Imbalance  to  Eye  disorders. 

5th.  Dynamics  of  the  eye  muscles  and  gymnastics  in  the  treat- 
ment of  them. 

6th.    As   to    Epilepsy,   Chorea,   Hysteria,   Migraine  etc.,   to  Asthen 
opia. 

7th.  The  Relation  o!  Eye  strain  <>r  Asthenopia  to  Constitu  ticna 
symptoms. 


PART  I. 

EXCERPTS  FROM  SPECIALISTS 
IN  OPHTHALMOLOGY. 


The  thoroughness  with  which  Prof.  Donders  of  Utrecht 
systematized  the  subject  of  Refraction,  would  be  difficult 
to  parallel    in  the  history  of  the  science  of  Medicine. 

Its  importance,  and  the  benefit  accrued  to  the  world, 
and  that  yet  to  come,  cannot  be  estimated.  He  wrote 
out  of  chaos,  mystery  and  ignorance,  a  beautiful  science 
and  habilitated  it  with  art,  order  and  precision.  He  put 
it  forth  on  the  road  to  exactness,  and  with  becoming 
modesty,  bid  it  improve. 


1864. 


F.  C.  DONDERS,  M.  D. 

Professor    of    Physiology    and    Ophthalmology    in    the    University    of 

Utrecht. 

Translated   by 
WILLIAM  DANIEL  MOORE,  M.  D. 


ANOMALIES  OF  ACCOMMODATION 
AND 
REFRACTION  OF  THE  EYE. 

Asthenopia. — Prof.  Donders'  early  history  of  asthenopia  tells 
us,  that  it  received  a  variety  of  names,  which  but  covered  up  ignor- 
ance of  the  phenomena.  "Dimness  of  vision" — "Affection  of  the 
retina  from  execssive  employment" — Disposition  to  fatigue" — 
"Slowly  adjusting  sight" — Impaired  vision  from  overwork.  "It 
is  evident  that  in  a  condition  such  as  this,  there  was  great  difficulty 
in  sketching  a  typical  picture,  so  long  as  the  cause  of  the  leading 
feature  of  the  affliction,  and  therefore  its  nature  was  unknown".... 


is  HAZEN'S    NEW    FINDINGS 

"The  well  defined  lineaments  of  the  picture    were    obliterated  by    un- 
ential    phenomena,   and    mixed    up   with   those  of  amblyopia.... 
and  were  generally  Bought  in  the  retina  or  in  the  choriadea." 

Early  Idea.      \s  to  the  affection  beingcaused  by  accommodation 

in    the    time    of     Mackenzie,     it  was     met    by    the    theory    of  Bohm 

ascribed  it  to  the  external  muscles  of  the  eye,  and  was  the  first 

-com mend  the  use  of  convex  glasses  for  the  trouble  of  asthen- 

.    but    lie   gave   too   weak   ones. 

Ruete  adopted  Bohm's  theory  and  concluded  that  the  "proxi- 
mate cause  ,  as  proved  by  Bohm,  was  a  weakness  of  the  motor 
nerves  of  the  eye."  From  the  fact  noticed,  that  complaints  were 
made  by  persons,  who  were  almost  constantly  occupied,  with  close 
work,  and  who,  on  its  suspension,  showed  immediate  improvement 
— it  was  asked,  should  not  the  affliction  be  considered  as  a  purely 
acquired  condition,  and  the  cause  of  it  be  sought  in  excessive  ten- 
sion?" Although  at  first,  asthenopia  lay  concealed  in  amblyopia, 
it  gradually  emerged  from  its  obscurity,  and  without  the  partici- 
pation of  the  retina  being  as  yet  denied,  its  seat  was  sought  more 
and  more,  in  the  organs  of  accommodation,  until,  at  last  the  retina 
was  almost  completely  excluded,  and  the  condition  was  looked 
upon  as  a  disease  of  the  motor  nerves  and  of  the  organ  of  motion 
of  the  eye." 

At  this  time  the  source  of  the  power  of  accommodation  had  not 
yet  been  discovered.  There  was  as  much  reason  to  assign  the 
principal  part  in  that  function  to  the  external  muscles  of  the  eye. 
This  led  to  the  supposition  that  asthenopia  was  to  be  sought  in 
a  spasmodic  contraction  of  some  external  muscle  of  the  eye." 
"The  cause  of  asthenopia  was  sought  in  the  external  muscles  of 
the  eye,  and  the  results  obtained  on  division  of  the  latter  were 
supposed  to  furnish  a  fresh  proof  of  the  correctness  of  the  views 
of  those  who  referred  it  to  them." 

After  Discovery  of  Accommodation. — After  the  discovery  of  the 
principal  of  accommodation,  nothing  more  was  said  of  the  principal 
of  abnormal  pressure  of  the  muscles  of  the  eye,  nor  of  dividing 
the  latter  as  a  remedy  for  asthenopia." 

Yon  Graefe,  "assigning  to  asthenopia  only  a  symptomatic  sig- 
nification, demonstrates  the  existence  of  asthenopia  muscularis, 
proceeding  from   insufficiency  of  the   musculi   recti   intend." 

Discovery  of  Hypermetropia. — "Our  knowledge  had  reached 
this  point,  when  I  discovered  the  cause  of  asthenopia  in  the  hyper- 
metropic structure  of  the  eye.     The  supposed   anomaly  of  accom- 


'  PROF.   F.  C.  DOXDERS  19 

initiation  then  became  an  anomaly  of  refraction.  The  connection 
of  asthenopia  with  the  circumstances  under  which  fatieuc  is  mani- 
fested was  made  most  clear;  the  necessity  of  complete  relief  by 
spectacles  was  proven,  while  at  the  same  time,  the  hope  of  a  radical 
cure  of  asthenopia   was  extinguished   forever." 

The  exaggerated  attention  to  the  external  muscles,  during  the 
period  of  operation  for  strabismus,  before  his  time,  he  thinks  caused 
the  pendulum  of  progress  to  swing  too  far  that  way. 

"We  must  beware  of  mistaking  apparent  for  true  asthenopia." 
Then  he  describes  a  case  of  undoubted  asthenopia  or  akinesis,  in 
which  he  finds  hyperesthesia  outside  and  in.  and  puts  on  dark 
glasses. 

ASTHENOPIA. 

Accommodation  and  Refraction. 

Symptoms. — "A  peculiar  morbid  condition  of  the  eyes  has  long 
attracted  the  attention  of  Ophthalmologists.  The  phenomena 
of  which  it  is  composed  are  highly  characteristic.  The  eye  has  a 
perfectly  normal  appearance;  its  movements  are  undisturbed; 
the  convergence  of  the  visual  lines  presents  no  difficulty;  the  power 
of  vision  is  usually  acute;  nevertheless,  in  reading,  writing,  and  other 
close  work — especially  by  artificial  light,  or  in  a  gloomy  place,  the 
objects  after  a  short  time,  become  indistinct  and  confused,  and  a 
feeling  of  fatigue  and  tension  comes  on — especially  above  the  eyes, 
necessitating  a  suspension  of  work.  The  person  so  affected  often, 
involuntarily,  closes  his  eyes,  and  rubs  his  hand  over  the  forehead 
and  eyelids.  After  some  moments'  rest,  he  once  more  sees  dis- 
tinctly, but  the  same  phenomena  are  again  developed  more  rapidly 
than  before."      (Sunday  interval-rest.) 

"The  tension  above  the  eyes  gives  place  to  actual  pain,  some- 
times even  slight  redness  and  a  flow  of  tears  ensue.  Everything 
is  diffused  before  the  eyes,  and  the  patient  no  longer  sees  at  first 
well,  even  at  a  distance.  After  too  long  continued  tension,  he  is 
obliged  to  refrain  for  a  long  time  from  any  near  work.  It  is  remark- 
able that  pain  in  the  eyes  themselves,  even  after  continued  exertion, 
is  of  rare  occurrence."  "At  first  this  condition  was  considered  as 
a  sort  of  amblyopia.     It  was  called  ihabitudeo  vises'."' 

Congenital  Predisposition  Explained. — "By  decrees  the  cause 
was  sought,  more  and  more  in  the  organ  of  accommodation — ;at 
first  in  the  action  of  the  external  muscles, subsequently,  in  that  of 
the  internal  muscular  elements,  and  in  the  same  measure,  the  impor- 
tance of  the  retina  was  thrown  into  the  shade.      Excessive  ten- 


SO  HAZEN'S   NEW   FINDINGS 

of  the  accommodation   was  looked   upon  as  a  satisfactory  cause  of 
the  troublesome  symptoms,  which,  it  was  hoped,  might  be  overcome 
by   rest."      "Since  the  same  cause  does  not  produce,   in  every  one, 
the  same   deviation,  writers  are  accustomed  to  take  refuge  in  a  pe- 
culiar   predisposition.      Thus    the  difficulty  is  set    aside,    but,    if    the 
foundation    of    this    peculiar    predisposition    be    dark    and    obscure, 
pathogeny   has  gained   but  little  from  the  adoption  of  this  course. 
I   therefore  felt  called  upon  to  propose  to  myself  the  question,  on 
what   the   so-called    predisposition    to   asthenopia    (so   the   condition 
was   now   more   generally  called)    might  depend   upon,   and   I   soon 
became  convinced   that  a   congenital  deviation,  namely,  a  moderate 
degree  of  hypermetropia    was  at  the  bottom  of    it.     The   hyperme- 
tropia    is    here,    however,    more    than    predisposition.      The    asthe- 
nopia— I  mean  the  tendency  to  fatigue  in  looking  at  near  objects,  is 
already  included  therein.      Every  hypermetropia,  which,  with  refer- 
ence to  the  range  of  accommodation,  has  attained  a  certain  degree, 
is,  at  the  same  time,  asthenopia.     If  the  symptoms,  sometimes  do 
not  manifest  themselves  until  twenty-five  years  of  age,  or  even  later, 
this  is  to  be  ascribed  merely  to  the  fact,  that  previously,  the  range 
of  accommodation   was   sufficiently   great,    to   easily   overcome   the 
existing   degree   of   hypermetropia."     "We   should    beware   of   con- 
founding the  exciting  circumstances  of  the  phenomena  which  con- 
sist in  continued  tension  in  looking  at  near  objects;  the  cause,  on 
the  contrary,  is   the   hypermetropic   structure   of   the   eye.      In   fact, 
asthenopia    is    not   fatigue   itself,    but   the   want   of   power    through 
which    the   fatigue   occurs.     The    distinction, made      here,    is   appli- 
cable to  other  conditions — for  example,   climbing  a   hill.      "I   have 
already   asserted   that   hypermetropia   is   usually   at   the   bottom   of 
asthenopia.      The    truth    of    this    assertion    has    been    doubted.      I 
now,  however,  go  a  step  farther,  and  venture  to  maintain,  that  in 
the  pure  form  of  asthenopia,  hypermetropia  is  scarcely  ever  wanting." 
'*\\  hen  inconvenience  was  felt  on  continued  exertion,  this  appeared 
to  some,  sufficient  to  justify  the  inference  that  asthenopia  existed. 
On  this  account,  different  forms  of  irritation,  congestion  in  myopic 
eyes,  hyperesthesia  of  the  eye,  with  increased  pain  or  exertion,  dif- 
ferent  affections   of   the   retina   and   of  the   choroid,    nay.   even   the 
beginning  of  trachoma,   and   foreign   bodies   in   the  sac  of  the   con- 
junctiva, might  all  be  united  under  one  denomination,  but  I  cannot 
concur   in   the   adoption   of  such   a    punitive,   semiotic   method.      It 
leads  inevitably  to  confusion  of  ideas  and  conditions.      "The  con- 
dition for  the  occurence  of  asthenopia  may  now  be  still  more  gen- 
erally formalized;   it  is  the  presence  of  a  rather  considerable,  but  yet 
at    the    same    time,    insufficient    ranee   of   accommodation.  Xow.  in 


PROF.  F.  C.  DONDERS  21 

general,  this  insufficiency  is  attributable  to  Hypermetropia,  as  has 
been  fully  explained,  but  it  may  proceed  also  from  want  of  energy. 
This  last  occurs  exceptionally — especially  in  general  weakness, 
from  loss  of  blood  or  otherwise,  and  in  paresis.  In  both  of  these 
conditions  there  is  this  peculiarity,  that  a  brief  but  rather  powerful 
muscular  exertion  is  possible,  but  that  the  energy  employed  is 
almost  immediately  lost.  We  observe  this  in  all  muscles,  and 
it  is  true  also  of  those  of  the  eye."  "There  arc  still  other  morbid 
states,  whose  symptons  have  some  resemblance  to  those  of  asthen- 
opia. To  those  belong  especially,  insufficiency  of  the  external 
recti  muscles,  which  Yon  Graefe  has  studied  with  such  excellent 
results — myopic  eyes,  where  this  insufficiency  is  more  particularly 
apt  to  occur." 

"This  form  was  distinguished  by  Von  Graefe,  under  the  name  of 
asthenopia  muscularis,  from  that  here  described  which  may  be 
here  called  the  accommodative  asthenopia." 

MUSCLES. 

Fatigue. — "The  phenomena  of  asthenopia  proceeds  from  nothing 
else  than  from  fatigue  of  the  muscular  system  of  accommodation. 
In  what  this  fatigue  consists,  deserves  to  be  more  closely  examined." 
"In  my  investigations  respecting  the  elasticity  of  muscles,  I  have 
distinguished  two  forms  of  fatigue."  "One  form  proceeds  from 
the  actual  energy  produced  by  the  muscle.  The  work  consists 
in  the  moving  of  a  load.  The  load  may  be  the  body  itself  or  some 
part  of  the  body,  which  is  moved,  or,  in  addition  thereto,  an  object 
external  to  the  body."  "Distinguished  from  this  is  the  fatigue, 
which  is  the  result  of  the  simple  extension  of  an  elastic  muscle  in 
state  of  contraction.  This  takes  place  when  a  burden  is  held 
without  being  moved,  as  for  example,  when,  with  the  arm  bent  at 
a  right  angle  at  the  elbow  joint,  the  hand  is  loaded  with  a  weight; 
the  arm  and  the  weight  remain  in  the  same  place  and  yet  fatigue 
soon  occurs."  "It  has  ,in  fact,  been  proved  that,  according  as  the 
muscle  becomes  fatigued,  its  extensibility  increases,  and  this  in- 
creasing extensibility  requires  augmenting  contraction,  in  order, 
under  the  extending  action  of  the  same  load  to  keep  the  muscle 
as  short  as  it  was."  "There  was  continually  some  actual  energy 
in  the  oscillations  of  the  electric  currents,  and  most  likely  converted 
into  heat."  "I  therefore  think  the  fatigue  proceeding  from  the 
performance  of  labor,  must  be  distinguished  from  that  arising  from 
simple  extension."  "In  explanation  of  the  fatigue,  which  is  the 
result  of  the  performance  of  labor,  we  may  take  refuge  in  an  accumu- 


22  HAZEN'S   NEW    FINDINGS 

lation  of  products  of  metamorphosis  of  matter  in  the  muscular 
tissue,  which  really  goes  hand  in  hand  with  it.  The  fatigue  pro- 
ceeding from  extension,  under  the  influence  of  a  load  not  further 
moved,  may,  partly  at  least  .have  another  source.  Thus  the  exten- 
sion might  give  rise  to  pressure  on  the  nerve  filaments  in  the  mus- 
cle." "Probably,  however,  it  depends  partly  also  on  an  increase 
of  the  products  of  the  metamorphosis  of  matter  in  the  muscular 
tissue,  produced,  not  so  much,  by  the  accelerated  formation,  as  by 
retarded  elimination."  "Now,  to  which  form  of  fatigue  does  that 
belong,  which  arises  from  persistent  accommodation  for  accurate 
vision  in  the  hypermetropic  eye?" 

Muscular  Asthenopia.— He  describes  Asthenopia  Muscularis 
under  the  head  of  Myopia.  "Diverging  Strabismus''  is  generally 
combined  with  Myopia."  He  says,  "in  cases  of  astigmatism, 
physical  fatigue  is  soon  created,  with  which,  under  some  circum- 
stances, as  the  result  of  the  excessive  tension  of  accommodation, 
phenomena   of  asthenopia   are  combined." 

Under  Myopia,  he  refers,  to  Von  Graefe's  operation  for  insuf- 
ficiency of  the  interni.  He  had  no  knowledge  of  prisms  as  a  means 
of  exercise,  but  refers  to  them  as  used  by  Yon  Graefe,  as  a  disagree- 
able means  of  correcting  diplopia  by  wearing  them. 

Insufficiency  of  Interni. — "If  the  one  eye,  so  soon  as  it  is 
covered,  preceptibly  deviates  outward,  and  on  removing  the  hand 
again  turns  inward,  in  order  to  resume  its  former  direction,  we  may 
suspect  the  occurrence  of  asthenopic  muscularis.  It  is  often 
difficult  enough  to  decide  what  is  to  be  done  in  such  cases,  for  the 
rules  applicable  to  insufficiency  of  the  internal  muscles  in  non- 
myopes,  by  no  means  hold  good  in  asthenopia  muscularis  in  myopic 
individuals.  In  the  former,  the  condition  referred  to  is,  in  the 
first  place,  free  from  danger,  and  it  is  even  allowable  to  try,  by 
systematic  practice  with  prismatic  glasses  to  excite  energy  of  the 
external  muscle.  In  myopia  on  the  contrary,  cure  of  the  insufficiency 
of  the  internal  recti  muscle  is  not  to  be  thought  of.  Once  begun,  the 
insufficiency  developes  itself,  more  and  more,  in  double  proportion 
when,  as  is  usual,  the  myopia  is  progressive.  Often  no  other  result 
is  possible,  than  the  exclusion  of  the  one  eye,  with  diverging  stra- 
bismus. In  the  worst  cases  the  mobility  is  even  so  limited,  that 
it   is   insufficient   both   inwardly   and   outwardly." 


There  was  a  notable  meeting  of  the  American  Ophthal- 
mological  Society  which  it  would  be  a  great  omission 
to  leave  out  of  a  history  of  the  subject,  which  we  arc 
endeavoring  to  elucidate.  This  paper  and  its  discussion, 
was  the  initiative  of  muscular  discipline,  as  a  remedy 
for  eye  strain,  and  awakened  a  new  idea  on  the  subject 
of  asthenopia  in  this  country. 

The  paper  was  given  in  a  full  meeting  at  which  many 
prominent  eye  men  were  in  attendance  and  took  part 
in  the  discussion. 

The  description  of  the  condition  of  these  cases  showed 
that  those  present  had  met  with  similar  experiences, 
and  the  discussion  was  animated  and  interesting.  (This 
is  but  a  synopsis  of  the  paper  and  its  discussion.) 

June,    ISO"). 

MEETING     OF     THE     AMERICAN     OPHTHALMOLOGICAL 
SOCIETY,  NEW  YORK  CITY. 

DR.   EDWARD   DELAFIELD,  President,   in  the   Chair. 

DR.  HENRY  D.  NOYES,  Secretary. 


"ASTHENOPIA  NOT  CONNECTED  WITH  HYPERMETROPIA." 

By 
E.  DYER,  M.  D. 

Asthenopia    with    no    Hypermetropia. — Dr.    Dyer    said,    "In 

these  cases,  there  was  no  hypermetropia,  latent  or  apparent." 
'"The  majority  of  his  cases  were  myopic;  good  accommodation; 
did  not  complain  of  words  becoming  indistinct,  but  had  absolute 
pain,   so  disagreeable  that   they  ceased   to   use   their  eyes;   rest  did 


24  MAXK.VS    NEW    FINDINGS 

not   relieve;  pain  or  sensation  lasted  for  several  hours,  sometimes, 

•     night   and    next    day;    some    intolerance    of   light;    could    go   to 

theater  or  opera  if  excited,  no  feeling  of  discomfort  at  any  time,  but 

the  next  day  or  two  would  suffer  the  penalty;  the  pain  produced 
by  indiscretions  of  this  kind  was  almost  exactly  like  that  brought 
on  by  using  the  eyes;"  (near  point)  is  mostly  found  in  persons  30 
years  of  age,  and  almost  restricted  to  persons  of  the  better  class 
of  society;  have  never  seen  it  in  strabismus  convergens,  but  some- 
times in  strabismus  divergens;  have  seen  only  one  case  complicated 
with  astigmatism.  The  Ophthalmoscope  generally,  shows  nothing 
abnormal;  frequently,  the  optic  nerve  is  not  clear."  He  was  led 
to  the  conclusion  that  there  was  some  trouble  with  the  accommoda- 
tion that  caused  the  pain,  but  in  emmetropia  and  in  myopia  both 
complain  of  asthenopia.  He  did  not  detect  insufficiency  of  conver- 
gence, but  thought  there  might  be  a  discrepancy  between  the 
power  of  the  ciliary  muscle  and  the  an^le  of  convergence. 

Discussion. 

Dr.  Dei. afield. — Dr.  Delatield.  said,  "He  had.  in  forty  years, 
seen  so  much  of  asthenopia  of  this  kind,  that  he  must  describe 
some  that  had  come  to  his  notice.  One  case,  the  wife  of  a  class- 
mate of  his,  had  not  read  or  written  since  1812;  another  of  the  same 
kind,  80  years  of  age,  with  the  same  effect:  the  disease  generally 
occurs  in  young  people,  but  no  aee  is  exempt  from  it;  the  common 
direction  is,  "to  rest  your  eyes."  He  never  knew  one  to  get  well 
by  resting  the  eyes.  The  difficulty  occurs  very  largely  in  girls' 
boaiding  schools  where  hysteria  is  seen,  and  bad  hygienic  measures 
are  found;  symptoms  are  very  much  alike;  the  variety  is  not  mate- 
rial; has  not  found  a  large  proportion  with  myopia;  after  using 
eyes,  "the  eye  sight  blurs." 

Dr.  Derby  divides  the  conditions  of  cases  of  asthenopia  into 
two  clasess — 1st.  those  where  continued  use  of  eyes  is  optically 
impossible.  2nd.  Those  where  the  same  is  physically  impossible. 
The  description  of  Donders  suffices  for  the  first,  and  the  symptoms, 
indistinctness  of  vision  from  effort,  with  pains  in  head,  flow  of  tears 
and  disposition  to  close  the  eyes,  the  second.  Under  one  or  other 
of  these  classes,  every  case  of  asthenopia  can  be  brought.  The 
physical  division  is  as  little  understood,  as  in  1858,  when  Donders 
first  wrote,  and  when  firmly  fixed,  is  as  little  amenable  to  treatment; 
often  absent  in  the  invalid,  and  present  along  with  the  most  vig- 
orous health — a  complete  enigma  as  to  its  seat,  its  cause  or  cure; 
more  common  in  this  country  than  in  F.urope,  and  more  common 
on  the  Atlantic  seaboard  than  in  the  West* 


NEW   YORK   OPHTHALMOLOGICAL   SOCIETY  25 

The  ocular  class,  generally  congenital,  is  reducible  to  two  causes, 
hypermetropia  and  insufficiency  of  the  internal  recti.  Out  of  the 
1800  cases  in  genera!  practice,  369  were  asthenopic;  of  these  '_' 1 1 
belonged  to  the  physical  and  125  to  the  ocular;  nearly  all  the  latter 
were  dependent  on  hypermetropia. 

In  true  asthenopia,  the  eye  is,  to  all  appearances,  botli  exter- 
nally and  internally,  absolutely  normal;  no  hypermetropia;  interni 
of  normal  strength;  general  health  may  be  satisfactory,  but  often 
is  not.  Sometimes,  under  the  influence  of  alcoholic  stimulus,  or 
the  excitement  of  important  business,  the  eyes  are  used  with  appa- 
rent ease,  and  when  excitement  ceases,  they  relapse  into  their  old 
condition.  The  affection  may  last  weeks  or  a  lifetime,  and,  in  the 
majority  of  cases,  resist  any  and  all  therapeutics. 

Dr.  Williams  of  Cincinnati. — Dr.  Williams  of  Cincinnati, 
during  a  number  of  years,  has  found  a  great  many  of  this  kind  ol 
cases,  that,  after  repeated  examinations,  have  excluded  all  idea  of  the 
usual  cases  of  asthenopia, such  as  myopia,  hypermetropia,  astigmatism 
or  paralysis  of  accommodation;  that  with  sight  perfect;  range  of 
accommodation  normal  and  ophthalmoscopically  perfectly  natural; 
the  patients  were  unable  to  use  their  eyes  an}'  length  of  time  without 
feeling  great  inconvenience.  These  cases  had  often  been  told  that 
they  were  threatened  with  amaurosis  and  must  not  use  their  eyes. 
This  apprehension  I  try  to  remove,  by  telling  them,  they  could  not 
get  blind  if  they  were  to  try.  From  much  reading  and  study,  my 
own  eyes  became  asthenopic,  and  I  became  apprehensive  that  I 
might  lose  my  sight,  and  Yon  Graefe,  on  examination  of  them  by 
the  Ophthalmoscope,  assured  me  that  there  was  but  a  little  nervous 
irritation,  and  I  have  done  nothing  for  them,  except  to  use  my 
eyes  a  little  more  reasonably.  One  case,  coming  to  me,  had  not 
read  five  lines  at  a  time  for  twenty  years.  I  fitted  the  Presbyopia 
and  she  has  been  using  her  eyes  as  much  as  she  pleased,  with  very 
little  inconvenience. 

Dr.  Williams  of  Bostox. — Dr.  Williams  of  Boston.  "My 
attention  was  drawn  to  these  cases,  (before  I  had  anything  to  do 
with  them)  which  were  called,  'morbid  sensibility  of  the  retina;' 
they  were  subjected  to  rather  an  active  treatment,  local  depletion 
and  low  diet,  and  directed  to  absolutely  refrain  from  the  use  of  their 
eyes.  These  patients  suffered  from  dread  that  they  were  to  be 
blind,  and  they  had  readily  taken  advice  to  refrain  absolutely  from 
using  their  eyes,  so  as  not  to  'strain  them."  and  sometimes,  they 
would  shut  themselves  into  a  dark  room.  A  charlatan  oi  the  early 
days,  with  a  good  deal  of  tact,  too!;  these  hysterical  patients,  and 


26  HAZENS   NEW    FINDINGS 

by  putting  them  to  bed  for  a  day,  with  strong  alkaloids  on  their 
eyes,  and  changing  the  diet  to  roast  beef  and  stimulants,  with  fre- 
quent drives  about  the  country,  taking  away  all  their  old  associa- 
tions, caused  his  patients  to  do  extremely  well,  and  the  quack  was 
considered  a  prophet.  He  ascribed  much  more  importance  to  the 
general  treatment  than  to  local  applications,  which  were  of  an 
haracter,  and  were  used  to  make  an  impression  on  the 
patient  rather  than  on  the  disease,  but  it  answered  the  purpose  in 
making  an  impression  on  the  disease  psychologically." 

*'In  Ophthalmological  examination  of  such  cases,  I  did  not  often 
rind  the  slightest  tendency  to  amaurosis,  and  I  encouraged  my 
patients  to  use  their  eyes  all  they  possibly  could.  I  prescribed 
tonics  and  placed  them  in  cheerful  surroundings,  instead  of  having 
their  minds  constantly  filled  with  morbid  fear,  and  I  sometimes 
gave  them  convex  glasses,  which  I  found  to  be  good  in  some  cases, 
not  knowing,  at  that  time,  much  about  hypcrmetropia.  as  we  now 
know   it. 

Dr.  Sands. — Dr.  Sands  reported  a  case  of  the  '"Optical  variety," 
coming  under  his  observation.  "A  young  man  at  17  years  of  age, 
living  in  Xew  England  had  been  sent  abroad  to  complete  his  educa- 
tion, and  also  to  spend  a  couple  of  years  in  Europe.  He  was  in 
perfect  health;  after  spending  two  or  three  months  about  the  Rhine 
and  in  Switzerland,  he  returned  to  Paris  and  began  to  experience 
pain  on  use  of  his  eyes.  He  had  never  been  a  very  hard  student 
and  he  was  very  much  surprised  at  the  occurrence,  and  went  to 
a  well  known  oculist  in  Paris,  who  told  him,  'that  he  was  suffer- 
ing from  hyperesthesia  of  the  retina.'  The  physician  created  an 
immense  amount  of  alarm  in  the  mind  of  the  boy,  and  placed  him 
under  treatment  of  a  complicated  character;  remedies  external  and 
internal;  told  him  to  avoid  use  of  his  eyes,  and  under  no  circum- 
stances to  apply  himself  to  work,  in  less  than  a  year.  His  parents 
sent  for  him  to  come  home,  and  he  consulted  me.  I  found  a  slight 
myopia,  accommodation  1-4,  vision  good,  no  blur;  the  pain  was  in 
the  ball;  could  discover  no  disease  by  ophthalmoscopic  examination, 
excepting  capillary  hyperemia  in  the  optic  nerves;  vision  above  nor- 
mal; physicial  health  good;  mental  depression  on  account  of  the 
advice  given  by  the  Paris  oculist.  He  suffered  no  pain  when  looking 
at  distant  objects,  but  only  when  the  ciliary  muscle  was  brought 
into  play  during  accommodation.  Following  Donders  in  'inordi- 
nate contraction  of  the  ciliary  muscle,'  I  prescribed  convex  glasses 
of  20  inch  focus,  but  when  the  optic  lines  were  made  to  converge 
upon  near  objects,  it  was  about  as  painful  as  it  had  previously  been 
to  exert  it  without  glasses. 


NEW  YORK   OPHTHALMOLOGICAL  SOCIETY  27 

Dondcrs  suspended  the  accommodation  by  atropine,  and  used 
convex  glasses  in  place  of  the  accommodation,  and  thus  cured  the 
spasmodic  contraction.  These  facts  lead  us  to  look  for  an  expla- 
nation of  asthenopic  symptoms  in  the  apparatus  of  accommoda- 
tion in  the  ciliary  muscle  and  the  nerves  that  supply  it,  rather 
than  in  the  errors  of  refraction  or  any  disturbance  relating  to  gen- 
eral health. 

Dr.  Noyes.  —  Dr.  Noyes  led  the  discussion,  which  thus  far  related 
chiefly  to  one  class  of  asthenopia.  "I  think  it  will  not  be  amiss, 
cursorily,  to  run  over  some  of  these  diseases,  which,  in  the  general 
classification  of  medical  men,  are  included  under  the  name  of  Asthe- 
nopia. Mackenzie,  I  find  to  be,  "Incapability  of  sustaining  the  eye 
in  adjustment  for  near  objects."  Lawrence,  "An  affection  of  the 
retina  from  excessive  employment,  commonly  called,  "weakness  of 
sight" — Mackenzie  grouping  symptoms  around  adjustment,  and 
Lawrence  grouping  the  symptoms  around  a  morbid  condition  of 
the  retina — Stellwag  Von  Corion,  "The  inability  to  keep  the  dioptric 
system  on  the  visual  lines,  for  a  long  period,  directed  to  near  objects; 
and  secondly,  in  close  pathological  relation  to  the  condition  hyper- 
aesthesia  of  the  retina  and  ciliary  nerves." 

"This  definition  of  asthenopia  is  unquestionably  the  definition, 
which  we  would  be  most  likely  to  adopt,  but  there  is  a  tendency  to 
exclude  from  the  definition  of  asthenopia,  all  those  cases  of  re- 
fractive errors  and  muscular  disturbances,  which  are  not  properly 
disturbances  of  the  ciliary  muscle,  but  include  cases  in  which 
neuralgic  symptoms  predominate.  This  is  the  meaning  which  the 
term  is  gradually  assuming.  Such  was  not  formerly  the  under- 
standing of  asthenopia,  and  we  all  know  perfectly  well  that,  at  least, 
two  or  three  well  recognized  sub-divisions  can  be  made — 1st. 
Errors    of   refraction,    principally    hypermetropia    and    astigmatism. 

2d.  Insufficient  power  of  the  internal  recti  muscles;  they, 
cannot  perform  their  work  of  converging  the  visual  lines,  when  the 
eyes  are  engaged  upon  near  objects.  3d.  Characterized  by  exces- 
sive irritability  of  the  retina,  accompanied  by  ciliary  disturbance 
or  neuralgia  of  the  eye,  extreme  intolerance  of  light,  with  no  lesion, 
no  organic  change,  with  vital  powers,  normal  standard.  Enough 
has  been  said  on  the  subject  of  hypermetropia,  astigmatism,  and 
myopia.  I  desire  to  recall  these  facts.  The  insufficiency  of  the 
internal  recti  muscles  has  a  nearer  relation  to  the  subject  of  asthen- 
opia, in  the  aspect  in  which  we  are  now  disposed  to  view  it,  than  to 
the  simple  errors  of  refraction,  because  this  muscular  part  requires 
to  be  exerted  in  all  use  of  the  eyes  upon  near  objects.    The  accom- 


28  HAZEN'S   NEW    FINDINGS 

modation  and  muscular  convergence  arc  inseparably  connected. 
The  correction  of  this  difficulty  is  accomplished  in  one  of  three  ways 
— division  of  the  external  recti  muscle;  by  use  of  prisms  or  what 
has  recently  been  suggested,  the  employment  of  electricity  to  the 
internal  recti  muscle  (Here  Dr.  Noyes  introduced  a  readier  method 
of  detecting  insufficiency). 

In  regard  to  cases  to  which  the  term  hyperesthesia  of  the  retina 
may  properly  belong — Case — A  physician,  a  surgeon  in  the  Navy, 
who  had  been  stationed  on  the  African  coast,  and  subjected  to  the 
intense  light  of  the  tropics;  extremely  sensitive  to  light;  he  not  only 
could  not  use  his  eyes  but  was  rarely  free  from  neuralgia.  He 
had  subjected  himself  to  all  sorts  of  treatment;  had  almost  poisoned 
himself  with  strychnine.  After  about  five  years,  he  came  under 
my  observation.  There  was  no  departure  from  normal  structure; 
no  deficiency  of  accommodation  or  any  other  function.  I  assured 
him  there  was  no  danger  of  becoming  blind,  and  that  he  would 
probably  be  better.  Out  of  door  exercise,  Avith  blue  glasses  and 
avoidance  of  the  use  of  his  eyes,  resulted  in  benefit,  and  after  about 
six  months  on  shore,  away  from  the  irritating  influences  to  which 
he  had  been  subjected,  he  recovered  the  use  of  his  eyes  and  again 
went  to  sea. 

Another  case — That  of  a  physician  with  the  same  misfortune — 
Ophthalmoscopic  examination,  with  as  little  gas  light  as  I  could  get 
along  with,  produced  agonizing  pain  for  24  to  48  hours;  attempts 
to  read  or  fix  eyes  on  distant  objects,  as  well  as  near,  provoked 
extreme  pain.  There  was  no  error  of  refraction,  impairment  of 
vision,  or  muscular  disturbance;  general  health  fully  up  to  the 
average.  I  could  regard  this  case  in  no  other  light  than  one  of 
extreme  irritability,  whose  starting  point  was  the  retina,  and  which 
was  reflected  upon  the  ciliary  muscles  and  nerves. 

These  several  categories  of  Asthenopia,  will  hereafter,  be  known 
by  their  proper  designation  of  errors  of  refraction,  debility  of  the 
internal  recti,  hyperesthesia  retina.  The  term  Asthenopia  is,  at  the 
present  time,  when  used  to  designate  a  distinct  disease,  and  not 
merely  a  symptom,  being  narrowed  down  to  cases  of  ciliary  spasm 
or  neuralgia." 

TREATMENT. — Dr.  Dyer  seems  to  be  the  first  one,  who  intro- 
duced a  system  of  gymnastics  for  the  muscles  of  the  eye,  which 
he  added  to  the  general  course  of  tonics  and  hygiene.  He  ''changed 
the  relation  of  the  accommodation  to  the  angle  of  convergence  of 
the  axes  by  glasses,"  by  giving  them  a  light  convex  glass.  He 
gave  them  explicit  directions  to  never  use  their  eyes  without  glasses, 


NEW  YORK   OPHTHALMOLOGICAL   SOCIETY  29 

and  never  use  them  except  as  directed.  Taking  the  clear  type  of 
medium  size,  the  patient  must  read  at  first,  from  3  to  15  minutes 
(according  to  the  case)  morning,  noon,  and  evening  (before  sunset) 
adding  a  minute  to  each  sitting;  if  pain  arose,  which  lasted  to  the 
time  of  the  next  reading,  make  the  time  a  minute  less,  but  always 
read  at  the  stipulated  time.  A  point  will  soon  be  found  at  which 
the  patient  can  read  without  pain — then,  to  the  time,  he  can  add 
a  minute  a  day,  and  when  he  gets  to  30  or  40  minutes,  three  times 
a  day,  he  may  use  his  eyes  at  other  work,  but  not  until  then.  When 
he  reaches  an  hour  of  reading,  the  glasses  may  be  dispensed  with. 

The  explanation,  the  rational  and  the  new  hope  held  out,  together 
with  the  mental  discipline  and  interest,  gives  to  these  cases,  who 
have  been  told  that  they  must  rest,  and  that  there  is  danger  of  their 
becoming  blind,  renewed  energy.  Out  of  forty  of  these  cases,  the 
results  have  been  highly  satisfactory. 

The  necessity  of  persevering  and  following  directions  is  emphasized. 
If  they  become  careless  and  read  too  much  or  irregularly,  they  will 
be  sure  to  be  thrown  back  and  have  the  whole  ground  to  go  over 
again.  The  treatment  of  these  cases  extends  over  months,  and 
they  often  relapse  from  indiscretion. 

Dr.  Delafield  considers  the  principle  of  Dr.  Dyer's  method  a 
correct  one  and  has  applied  it  for  years — that  is —  in  general  dis- 
eases, he  insists  on  exercise.  He  says,  "The  cure  of  the  patient's 
general  health  is  the  foundation  of  everything.  I  am  specific  in 
direction  as  to  this.  Locally,  I  apply  a  sol  of  veratria  or  aconite 
to  the  nape  of  the  neck,  and  from  this  application,  urge  them  to 
read  fifteen  minutes.  I  sometimes  use  ammonia  and  alcohol, 
applied  to  the  forehead,  temples  and  neck.  Each  day  one  of  these 
is  used.  I  have  used  a  solution  of  a  grain  of  veratria  to  the  ounce, 
dropped  into  the  eye,  in  obstinate  cases  of  asthenopia.  It  is  painful 
and  I  get  along  without  when  I  can."  The  exercise,  instituted  by 
Dr.  Dyer,  called  for  the  forced  use  of  the  eyes  not  stopping  because 
of  pain. 

Dr.  Derby. — The  original  method  of  treating  asthenopia,  was 
neutralizing  the  manifest  hypermetropia  and  keeping  pace  with 
the  manifest,  until  all  became  manifest.  Much  stress  was  laid 
on  the  necessity  of  making  the  neutralizing  glass  part  and  parcel 
of  the  eye,  and  only  laid  aside  when  the  eye  ceased  to  see.  It  is 
now  proved  that  the  assumption  that  accommodation  cannot  be 
used  on  distant  objects  without  injury,  is  fallacious.  We  may 
therefore,  allow  the  patient,  who  sees  distant  objects  fairly  well, 
to  use  his  glasses  only  for  the  near. 


30  HAZEN'S   NEW   FINDINGS 

Dr.  WILLIAMS  of  Cincinnati,  believed  in  exercising  the  eyes  and 
had  used  Dr.  Dyer's  system,  without  exactly  knowing  why.  He 
I,  "I  have  tried  it  in  two  cases.  I  used  moderately  convex 
g'asses  and  applied  a  solution  of  the  sulphate  of  morphia — two 
grains  to  ounce — dropping  three  or  four  drops  into  the  eyes,  three 
or  four  times  a  day.  Gave  tonics  constitutionally,  and  douched 
the  eye  with  cold  water  twice  a  day." 

Dr.  \\  illiams  of  Boston — .Constitutional  medicine,  tonics  and 
moderate  exercise.  No  use  of  eyes  when  ill.  Found  glasses  were 
of  benefit  in  hypermetropia.  Encouraged  patients  to  use  eyes, 
increasing  their  use  gradually. 

Dr.  Noyes,  considered  the  system  of  Dr.  Dyer,  in  using  a  convex 
glass  required  a  little  greater  effort  of  the  internal  recti,  by  bringing 
the  near  point  nearer,  while  a  systematic  training  developed  their 
strength.  He  says,  "I  have  seen  benefit  from  wearing  weak  prisms 
when  I  did  not  feel  certain  that  the  interni  were  at  fault.  A  com- 
bination of  -f-  1.  D.  C  2°  prism  has  relieved  a  troublesome  asthen- 
opia. \\  ith  these  contrivances,  there  occurs  a  change  in  the 
relative  accommodation — not  as  by  use  of  convex  glasses,  yet 
the  eyes  accommodate,  under  conditions,  unlike  those  to  which 
they  have  become  accustomed. 

It  was  brought  out  in  the  discussion,  by  inquiry,  that  Dr.  Dyer 
had  no  particular  method,  besides  those  commonly  used,  to  deter- 
mine whether  his  patients  had  insufficiency  of  the  interni.  He  was 
satisfied  to  change  the  relation  beiween  accommodation  and  con- 
vergence, and  endeavored  to  establish  a  more  perfect  relation 
between  the  two.  He  said,  "I  have  doubted  whether  the  benefit 
derived  from  prisms,  was  because  of  the  relief  to  the  internal  recti, 
and  not  rather  because  of  the  modification  in  the  condition  of  accom- 
modation." 

Dr.  Althof  had  seen  a  great  deal  of  the  application  of  electric- 
ity to  the  eyes,  but  had  never  seen  any  benefit,  whatever,  derived 
from  the  use  of  it.  As  far  as  the  treatment  of  these  cases  of  asthen- 
opia, by  glasses  was  concerned,  it  was  becoming  more  important 
and  if  the  providing  of  glasses  were  facilitated,  there  would  be  less 
of  asthenopia.  High  degrees  of  insufficiency  do  not  always  show 
diplopia  with  red  glass. 


The  early  history  of  the  specialty  of  Ophthalmology 
in  this  country,  received  much  of  its  impetus  through 
the  labors  of  Charles  Bader,  as  shown  in  the  following 
named  book — although  it  was  published  in  England. 

1868. 

THE  NATURAL  AND  MORBID  CHANGES 

OF  THE 
HUMAN  EYE  AND  THEIR  TREATMENT. 

By 

CHARLES    BADER, 
Ophthalmic     Assistant     Surgeon     to     Guy's     Hospital. 

Asthenopia. — Weak  sight,  impaired  vision,  slowly  adjusting 
sight,  affection  of  the  retina  from  excessive  employment.  The 
two  groups  of  muscles,  which,  from  want  of  power,  may  give  rise 
to  asthenopia,  are  the  ciliary  muscle  and  the  external  muscles  of 
the  eye  ball. 

The  term,  Accommodative  Asthenopia  has  been  used  by  some  to 
distinguish  asthenopia,  which  is  due  to  want  of  power  of  the  ciliary 
muscle.  Many  symptoms  accompanying  asthenopia,  do  not  essen- 
tially belong  to  it.  In  true  asthenopia,  when  engaged  in  "near 
work,"  letters  or  finer  details  become  "dim"  or  disappear.  After 
rubbing  or  closing  the  lids,  they  can  resume  work  for  a  short  time; 
attacks  of  dimness  vary  in  frequency;  they  appear  sooner  in  ill 
health;  they  may  continue  for  years  without  interfering  with 
acuteness  of  vision.  In  hypermetropia,  dimness  is  preceded  by 
sensations  of  tension  over  eyebrows,  amounting  sometimes  to  pain. 
It  has  been  stated,  that  the  age  at  which  asthenopia  appears,  is 
about  equal  to  the  denomination  of  the  fraction  (inch  system) 
which  expresses  the  deeree  of  hypermetropia.  Only  the  true  asthen- 
opia, as  a  rule,  is  cured  by  convex  glasses. 


32  HAZEN'S  NEW  FINDINGS 

Apparent,  Not  True  Asthenopia. — Patients,  at  near  and  dis- 
tant vision,  complain  of  pain,  aching,  watering,  pain  in  ciliary 
region  and  back  of  eyes.  Pain  may  he  permanent  and  increased 
when  attempt  is  made  to  work.  Tension,  smarting,  photophobia 
and  occasionally  phosphenes,  dimness  of  vision  arc  felt,  but  it  is 
the  pain  etc.,  which  compels  the  patient  to  desist  from  work,  often 
tor  months.  Apparent  Asthenopia  often  occurs  in  Myopia,  and 
occasionally  in  hyperemia  of  the  optic  disc  and  retina,  and  is  termed 
hyperaesthesia  of  the  retina  if  no  organic  changes  are  discernible. 
Asthenopia  arising  from  weakness  ("insufficiency")  of  the  internal 
recti  muscles — by  some  termed  muscular  asthenopia,  is  often  met 
with  in  Accommodative  Asthenopia,  and  is  sometimes  mistaken 
for  it. 

Insufficiency   of   the   Internal    Recti    Muscles. 

Insufficiency  of  the  Converging  Power  of  the  Eyes — Asthen- 
opia Muscularis. 

''In  Insufficiency,  the  associated  movements  of  both  eyes  are 
normal — not  so  in  Paresis."  Insufficiency  of  the  internal  recti 
muscles  signifies  want  of  power  in  these  muscles.  The  sub- 
jective symptoms  of  the  insufficiency  are,  in  a  great  measure,  those 
of  asthenopia,  and  in  every  case  of  asthenopia,  Ave  should  ascertain 
the  power  of  the  internal  recti  muscles.  The  asthenopia  caused 
by  insufficiency,  is  termed  muscular  asthenopia.  The  weaker  eye 
diverges  first.  We  suppose  the  insufficiency  to  be  pretty  equal, 
if,  at  one  moment  one,  at  another  the  other  eye,   diverges. 

Screen  Test. — If  we  find  that  the  excluded  eye  diverges,  we 
infer  that  the  converging  power  of  that  eye  is  insufficient.  By 
Von  Graefe's  test,  it  is  further  established.  If,  before  the  prism 
with  the  angle  upward  (which  causes  the  dot  and  line  to  double) 
a  second  prism  with  the  refracting  angle  outward,  will  measure  the 
degree  that  will  unite  the  two  images.  For  Insufficiency  at  a  dis- 
tance, use  the  flame  of  a  candle  and  determine  the  prism  that  can 
be  overcome  by  convergence,  and  what  prism  can  be  overcome  by 
divergence.  The  power  of  divergence,  in  these  cases,  is  generally 
greater.  Weakness  of  these  muscles  is  often  congenital  and 
hereditary. 

Treatment. — "Asthenopia,  whether  true  or  apparent,  is  a 
symptom,  which,  as  a  rule,  subsides  under  proper  treatment  of 
its  cause. 


CHARLES   BADER  33 

Correction  of  the  Refraction. — In  Insufficiency,  we  often 
succeed  in  removing  the  asthenopia,  caused  by  it,  through  optical 
or  surgical  means  or  by  combining  of  the  two.  In  case  the  refrac- 
tion is  normal  and  the  eyes  are  otherwise  healthy,  if  divergence 
exist  to  the  extent  of  l°or  1^°,  we  recommend  prismatic  spectacles 
with  refracting  angle  turned  outward.  "The  external  recti  must 
be  made  to  contract,  and  the  internal  ones  to  relax.  "Tf,  as  in 
paresis  of  the  internal  recti  muscles,  it  is  desirable  to  excite  and 
practice  contraction  of  these  muscles,  we  reverse  the  position 
of  the  prisms."  We  give  prisms  of  equal  strength  to  both  eyes. 
If  the  strength  of  the  correction  exceeds  10°  or  12°,  we  divide 
the  external  rectus  of  the  eye,  which  diverges  most  on  exclusion." 
We  divide  both  external  recti  muscles,  if,  in  each  eye,  the  outward 
movement  exceeds  60°.     He  explains  decentering  of  lenses. 

Operation. — The  object  of  operation  is  to  facilitate  the  con- 
traction of  the  internal  recti  muscles. 


The  prominence  of  the  German  works  in  former  years, 
and  especially  those  translated  by  our  well  known  Amer- 
ican, Dr.  Roosa,  makes  it  necessary  that  their  thought 
on  the  sunbject  of  Astheopia,  in  relation  to  the  Function 
of  Vision,  should  be  represented  in  its  history. 

1868 

CARL  STELLWAG  VON  CARION,  M.  D. 

Professor    of    Ophthalmology    in    the    Imperial    Royal    University    of 

Vienna. 

TREATISE    ON   THE   DISEASES    OF   THE   EYE. 

Translated  by 

CHARLES  E.  HACKLEY,  M.  D. 

Surgeon  to  the  New   York  Eye  and  Ear  Infirmary,  Physician  to  the 
New  York  Hospital,  Fellow  of  the  New  York  Academy  of  Medi- 
cine, etc. 

D.  B.  ST.  JOHN  ROOSA,  M.  D. 

Clinical  Professor  of  the  Eye  ansd  Ear  in  the   Medical  Department 
of  the  City  of  New  York,  etc. 

Asthenopia. — "By  Asthenopia,  we  understand  the  inability  of 
maintaining  the  adjustment  of  the  dioptric  apparatus,  or  the 
visual  axis  for  short  distances,  for  a  length  of  time,  and  the  hyper- 
aesthsia  of  the  retina  and  ciliary  nerves  accompanying  this  inabil- 
ity." 

The  cause  of  the  disease  is  sometimes  an  absolute  or  a  relative 
deficiency  of  energy  in  the  muscle  of  accommodation;  at  others 
it  is  a  similar  affection  of  the  internal  recti  on  which  depends  the 
convergence  of  the  optic  axes.  Accommodative  Asthenopia  is  most 
frequently  seen.  When  the  functional  stamina  has  much  decreased, 
and  pain  arises  with  swimming,  they  announce  themselves  by  a 
feeling  of  fullness  in  the  eye,  with  peculiar  tension  in  the  forehead, 
then    over   the   eyes;   soon    dizziness,    headache,    malaise   and   even 


36  HAZEN'S  NEW  FINDINGS 

nausea,  almost  always  injection  of  the  conjunctiva;  episclera  as 
well  as  lachrymation.  Muscular  asthenopia  is  much  less  frequent. 
The  subjective  symptoms  are  similar  to  those  of  the  accommo- 
dative form;  only  the  retina  does  not  have  to  contend  with  circles 
of  dispersion.  Patients  complain  more  of  the  neighboring  letters 
running  together  and  through  each  other;  this  is  preceded  by  a 
straining  sensation.  Double  vision  occurs,  assistance  comes  by 
removing  objects  to  a  greater  distance.  Many  patients  prefer 
to  shut  the  weaker  eye  or  move  the  object  to  the  affected  side, 
diminishing  the  amount  of  action  required  of  it.  '"In  muscular 
asthenopia  a  long  interruption  of  work,  or  nightly  rest  does  not 
suffice  to  produce  an  increased  duration  of  function;  the  energy  of 
the  internal  recti,  once  decreased,  is  again  aroused  with  much  more 
difficulty,  and  more  slowly  than  that  of  the  muscle  of  accommo- 
dation." On  fixing  at  a  near  point,  one  eye  becomes  uncertain  and 
finally  turns  outward.  In  tests  of  double  image  caused  by  prisms, 
there  are  crossed  images  produced.  In  emmetropes  myopes,  ac- 
commodative asthenopia  rarely  occurs,  but  such  eyes  are  not 
perfectly  safe  when  there  is  muscular  insufficiency.  The  internal 
r  ecti  are  most  called  on  in  high  grades  of  myopia,  hence  muscular 
asthenopia  principally  affects  the  near  sighted.  Muscular  asthen- 
opia occurs  more  rapidly  if  there  is  also  a  congenital  or  developed 
deficiency  of  energy  of  the  internal  recti.  These  insufficiencies 
often  occur  and,  as  they  are  not  combined  with  great  myopia,  it 
shows  that  muscular  asthenopia  may  also,  under  certain  circum- 
stances, occur  in  slightly  myopic  or  even  emmetropic  or  hyper- 
metropic persons.  This  would  be  practically  liable  to  occur,  when 
an  unaccustomed  strain  of  the  muscle  of  convergence  offered  the 
opportunity.  At  first,  symptoms  appear  wrhen  the  affected  muscle 
is  subjected  to  unaccustomed  straining.  With  continued  forced 
work,  the  nervous  symptoms  soon  become  permanent — dazzling 
even,  in  slight  use  of  the  eye  as  in  distant  vision,  exciting  severe  pains 
in  and  around  the  eye.  The  asthenopia  acquires,  more  and  more, 
the  character  of  retino  ciliary  hyperaesthesia. 

Causes  of  Asthenopia. — Among  the  causes  of  asthenopia,  he 
gives  the  doctrine  of  Von  Graefe.  "The  overburdening  of  the  mus- 
cle of  accommodation  or  of  the  internal  recti.  Frequently  such 
insufficiences  are  congenital,  or  even  hereditary — hence  affect 
unproportionally,  members  of  the  same  family,  and  unfavorable 
circumstances  almost  always  occur  if  the  patient  strain  his  eyes 
too  soon.  Hypermetropia  furnishes  by  far  the  greatest  number 
of     cases     of     accommodative     asthenopia.     Muscular     asthenopia 


CARL  STELLWAG  VON  CARION,  M.  D.  37 

principally  affects  the  near  sighted,  because  the  near  approach  of 
the  object  and  the  position  of  the  point  of  rotation  overburdens 
the  converging  muscles.  This  excessive  work,  imposed  on  the 
interna!  recti  of  very  short  sighted  persons,  who  are  employed  with 
small  objects,  does  not  always  produce  muscular  asthenopia,  because 
the  error  of  refraction  generally  increases  and  the  energy  of  the 
muscles  increases  as  the  tendency  to  asthenopia  diminishes.  Later 
in  life,  posterior  staphyloma  increases  rapidly.  Muscular  asthenopia 
occurs  in  congenital  or  developed  deficiency  of  energy  of  the  inter- 
nal recti.  These  insufficiencies  often  occur,  under  certain  circum- 
stances, in  slightly  myopic  or  even  emmetropic  or  hypermetropic 
persons.  Evertion  seems  to  be  limited  from  parallelism;  voluntary 
adduction  always  remains  in  excess.  If  there  is  insufficiency  of 
one  or  both  internal  recti  and  consequent  asthenopia,  abduction 
is  favored.  At  the  distance  of  the  ordinary  occupations,  much 
stronger  prisms  can  be  overcome,  when  the  angle  is  outward  than 
when  it  is  inward.  Even  when  the  distance  is  greater  the  abduction 
still  preponderates,  so  that  quite  strong  prisms  can  be  overcome, 
when  the  angle  is  outward,  while  even  weak  ones,  with  the  angle 
inward,  excite  unbearable  diplopia.  A  prism  of  24°,  angle  inward, 
overcomes  at  ten  inches,  but  with  this  angle  outward  30°, 
and  if  the  lateral  deviation  were  80°,  there  would  be  only  a 
slight  tendency  to  muscular  asthenopia,  as  the  insufficiency  is  only 
one  third  of  the  abduction. 

"Among  the  special  causes  of  muscular  asthenopia,  are  sudden 
and  powerful  disturbances  of  the  associations  existing  between  the 
innervation  of  the  muscle  of  accommodation  and  the  lateral  muscles 
of  the  eye  ball."  They  will  arise  with  some,  who  are  accustomed 
to  glasses  and  take  them  off;  or  in  putting  them  onto  those  not 
accustomed  to  any.  The  muscle  of  adaptation  is  compelled  to 
exert  or  relax  quite  differently,  than  was  formerly  required,  with 
equal  convergence  of  the  optic  axes.  The  disproportion  is  not 
endured  and  fatigue  comes  and  soon  asthenopia. 

"It  is  a  probable  supposition  and  confirmed  by  careful  observation, 
that  insufficiency  of  the  external  recti,  with  asthenopia,  may  also 
occur." 

Course  and  Results.. — Asthenopia  is  capable  of  cure.  It  is 
especially  true  of  those  cases  in  which  it  is  not  so  much  an  actual 
want  of  energy,  that  causes  the  disease,  as  an  absolute  excess  of 
required  action,  and  of  those  cases  in  which  diseases  and  the  general 
and  local  weakness  they  cause,  have  diminished  the  working  power 
of  the  eye,  and  so  placed  the  cause  of  the  asthenopia  in  connection 


38  HAZEN'S   NEW  FINDINGS 

with  overburdening.  Where  a  certain  deficiency  of  energy  is  the 
cause  of  the  development  of  asthenopia,  the  eye  never  returns  to 
normal  duration  of  function.  Throughout  life  it  requires  certain 
helps,  which  in  ordinary  occupations,  diminish  the  amount  of  work 
to  the  existing  power. 

The  translator  adds,  "that  under  the  belief  that  in  asthenopia 
there  was  often  a  discrepancy  between  the  power  of  the  ciliary 
muscle  and  the  angle  of  convergence,  it  was  concluded  that  there 
was — 1st.  Some  disturbance  of  the  relative  accommodation. 
2d.  There  seems  to  be  a  want  of  tone  or  power  of  the  ciliary 
muscle  for  continued  action.  3d.  Want  of  mental  energy,  the 
patient  having  lost  confidence  in  his  power  to  use  his  eyes. 

He  then  describes  Dr.  Dyer's  method  of  discipline,  explained 
in   this   digest. 


The  work  of  J.  Soelberg  Wells,  has  figured  largely, 
for  a  certain  period,  in  Ophthalmology  in  this  country. 
The  clear  and  easily  comprehended  expressions  of  the 
text  is  one  of  the  valued  remembrances  of  its  use,  and 
the  advanced  course  in  the  particular  subject,  which  is 
our  present  study,  is  another  cause  for  finding  a  niche 
for  it  in  our  history. 

1869 

A    TREATISE    ON    THE    DISEASES    OF    THE    EYE. 

American  Edition. 

J.  SOELBERG  WELLS. 

Professor    of   Ophthalmology    in    Kings'     College,    London.     Ophthal- 
mologic al   Surgeon   to    King's    College   Hospital,   and   Assis- 
tant Surgeon  to  the  Royal  Ophthalmic  Hospital, 
Moors  fields. 

ASTHENOPIA. 

Accommodation. — Hypermetropia  is  a  very  frequent  cause  of 
asthenopia.  This  accommodative  form  of  asthenopia  must  be 
distinguished  from  the  muscular,  which  depends  upon  the  weakness 
of  the  internal  recti  muscles,  and  also  from  the  retinal  asthenopia. 
The  latter  is  generally  due  to  hyperesthesia  and  irritability  of  the 
retina,  accompanied  by  hyperemia  of  the  optic  nerve  and  retina." 
"It  mostly  occurs  in  feeble,  nervous  and  excitable  persons — espec- 
ially females." 

Muscular  Asthenopia. — This  affection  is  of  common  occurrence, 
and  is  characterized  by  very  marked  symptoms  of  Asthenopia, 
which  sometimes  prove  so  irksome  and  harassing  to  the  patient  as 
to  incapacitate  him  for  reading  etc.  Such  patients  complain,  that, 
after  they  have  been  working  or  reading  for  a  certain  length  of  time, 
the  letters  become  confused   and   run  into  or  overlap  each  other. 


40  HAZEN'S  NEW  FINDINGS 

This  is  generally  preceded  by  a  feeling  of  tension  or  weight,  in  the 
and  over  the  brow,  and  some  patients  distinctly  feel  how  the 
one  eye  becomes  unsteady  and  wavering,  and  then  moves  gradually 
outward.  They  also  anticipate  these  symptoms  by  closing  one  eye. 
Alter  resting  for  a  short  time,  reading  may  be  resumed,  to  be, 
however,   again   interrupted   by   the  same   train   of  symptoms. 

He  measured  the  deviation  of  the  lateral  muscles,  at  a  distance 
as  well  as  near,  by  the  use  of  a  prism,  with  axis  vertical,  This, 
he  says  is  a  much  more  delicate  test  than  that  of  covering  one  eye 
with  the  hand,  for  it  will  enable  us  to  detect  degrees  of  deviation 
of  the  optic  axes,  which  are  too  slight  to  be  appreciated  by  the  eye. 
He  gives  the  dot  and  line  test  of  Von  Graefe.  After  the  presence 
of  insufficiency  and  its  degree  have  thus  been  determined,  he  tests 
the  relative  strength  of  the  external  recti  of  each  eye,  by  ascertaining 
the  strongest  prism,  which  it  is  able  to  overcome  at  a  distance  of 
from  G  to  10  feet.  He  says,  "Place  prisms  of  various  strength  before 
one  eye,  turning  the  base,  first  outwards  in  order  to  find  the  strong- 
est, with  which  a  patient  sees  singly,  and  this  gives  the  strength 
of  the  internal  rectus.  The  external  rectus  of  the  same  eye  is 
to  be  tried,  and  the  other  eye  should  be  examined  in  the  same  man- 
ner. Insufficiency  of  the  internal  recti  is  most  frequently  met  with 
in  cases  of  considerable  myopia,  but  a  temporary  insufficiency  of 
the  internal  recti  may  also  be  produced  by  severe  constitutional 
diseases,  which  greatly  weaken  the  system.  It  may  co-exist 
with  hypermetropia,  and  it  should  always  be  suspected  if  the 
symptoms  of  asthenopia  persist,  in  spite  of  the  use  of  convex  lenses. 

"The  internal  recti  may  be  strengthened  by  frequent  exercises 
with  prisms  (whose  base  is  turned  outward).  The  object  (a  lighted 
candle,  white  wand,  etc.)  is  to  be  placed  at  a  distance  of  6  to  8 
feet  and  a  prism  with  its  base  outwards  should  be  held  before  one 
eye.  Crossed  diplopia  will  be  produced,  and  in  order  to  overcome 
this  the  patient  will  squint  inwards.  The  strength  of  the  prism 
may  be  gradually  increased  but  should  not  be  too  strong  at  first, 
otherwise   the   internal   rectus  will  be  weakened   by  over-exertion." 

Strabismus. — The  nature  of  strabismus  is  totally  different  from 
that  of  the  paralytic.  In  the  latter,  the  innervation  of  one  or  more 
of  the  muscles  of  the  eye  ball  is  impaired;  whereas,  concomitant 
squint  is  due  to  a  change — an  increased  degree  of  tension  in  the 
muscles  in  the  direction  in  which  the  squint  occurs,  but  its  inner- 
vation is  normal,  as  is  at  once  proved  by  the  perfect  mobility  of 
the  eyeball    in    this  direction,  and  by  the  fact  that  the  secondary 


J.    SOELBERG  WELLS  41 

deviation  exactly  equals  the  primary,  and   does   not  exceed  it,   as 
in  the  case  of  paralysis. 

Treatment. — As  Hypermetropia  is  the  most  frequent  cause  of 
convergent  squint,  Myopia  is  the  most  frequent  cause  of  divergent 
squint.  He  advocated  operation,  and  recommended  prismatic 
lenses  to  aid  the  internal  recti;  correction  of  hypermetropia  with 
convex  lenses,  and  corrected  myopia  with  concave  lenses,  and  decen- 
tering  of  lenses  to  aid  the  muscles. 


Dr.  Noyes  of  New  York  was  a  conspicuous  figure  in 
the  dissemination  of  the  science  of  Ophthalmology  by 
his  writings,  teachings,  and  clinical  work.  He  added 
many  devices  and  improvements  in  instruments  and 
facilities  in  ophthalmological  work — and  displayed  a 
genius  in  systemization  and  the  making  of  new  applica- 
tions to  conditions,  which  he  differentiated  in  his  study 
of  cases. 

1875—1890 
HENRY  D.  NOYES,  A.  M.,  M.  D. 

Professor  of  Ophthalmology  and  Otology  in   Bellevue  Hospital  Medi- 
cal College;  Executive  Surgeon  to  the  New  York  Eye  and  Ear  In- 
firmary, etc. 

PAPER  IN  THE  TRANSACTIONS  OF  THE  INTERNATIONAL 
OPHTHALMOLOGICAL  CONGRESS.     1876. 

Asthenopia. — In  his  analysis  of  1079  cases  of  Ametropia  and 
Muscular  weakness  with  deductions  respecting  asthenopia,  at  the 
Congress,  he  notices  the  difficulties  of  authors  in  cases  of  asthenopia, 
which  do  not  come  under  the  category  of  Donders'  or  Graefe's 
systems,  but  are  thrown  out  as  "apparent"  or  "false"  asthenopia. 
He  uses  the  "word  asthenopia  as  a  generic  term  and  not  as  being 
itself  a  disease."  The  cases  of  opacity  of  the  cornea,  incipient 
cataract,  posterior  synechia,  a  turbid  vitreous  or  any  slight  retinal 
or  charoidal  affection  may  cause  asthenopic  symptoms,  but  these 
are  placed  in  their  true  category.  As  in  Amaurosis,  Asthenopia 
is  a  generic  term.  "The  word  has  become  current  as  a  general- 
ization to  distinguish  those  cases  in  which  the  use  of  the  eyes  causes 
pain  or  difficulty,  and  this  when  there  is  no  ideopathic  inflammation 
nor  any  opacity  of  media." 


44  HAZK.VS    Xi:\V    FINDINGS 

We  condense  his  recital  of  the  symptoms. — 

SYMPTOMS. — 1st.  The  cardinal  symptom  is  pain,  acute  or  dull, 
on  efforts  of  use  of  eyes,  near  or  remote,  aggravated  by  bright 
light;  it  may  be  called  by  different  names;  "aching,"  "a  tired  feel- 
in-:."  "weariness,"  "soreness,"  "inability  to  look  at  anything," 
a  horror  of  print,"  "acute  pain,"  "dull  pain,"  etc.  The  seat 
may  be  in  the  eyeballs,  supra-orbital  or  deep  in  the  orbit;  in  the 
inner  or  outer  angles,  forehead  or  face,  headache;  sometimes  any 
movement  or  fixation  of  the  eyes  is  painful.  Looking  at  rapidly 
moving  objects,  either  when  passing  or  riding.  The  most  common 
occasion  of  pain  is  looking  at  near  objects.  Pain  is  produced  by 
moving  the  eyes  across  the  page,  and  by  looking  up  or  down  to 
extreme  lateral  positions. 

2d.  Next  in  frequency  comes  smarting  of  the  eyes  as  of  foreign 
body  under  the  lids;  sometimes  lachrymation.  To  relieve  the  feel- 
ing, patients  rub  or  press  on  the  eyeballs  and  often  suppose  the 
slight  inflammation  to  be  the  cause  of  distress.  Physicians,  too 
often,  so  regard  it,  and  prescribe  without  making  deeper  inquiries. 
This  irritation  has  been  noted  by  Donders  and  others.  In  my 
practice  I  find  it  noted  in  158  cases.  Under  conjunctival  irritation 
is  included  blepharitis  ciliaris,  blepharitis  angularis,  hordeola, 
cystic  tumors  and  phlyctenule  as  well  as  congestion  of  the  pal- 
pebral or  ocular  conjunctiva;  all  these  conditions  are  extremely 
prone  to  attend  upon  asthenopic  troubles,  which,  sometimes,  will 
not  yield  to  any  treatment,  local  or  general,  until  the  asthenopic 
symptoms  (causes)  are  removed.  These  symptoms  should  be  a 
sufficient  presumption  to  cause  inquiry  into  the  functions  of  the  eye. 

3d.  Blur  or  confusion  or  indistinctness  in  reading,  writing, 
etc.  Blur  or  indistinctness  characterizes  refractive  and  accommo- 
dative asthenopia  and  double  vision,  muscular  asthenopia. 

4th.  There  is  always  inability  for  or  discomfort  under  sustained 
effort  at  near  objects. 

5th.  Headache.  In  refractive  errors — especially  in  astigmatism, 
it  may  be  of  constant  or  frequent  occurrence  and  independent  of 
use  of  the  eyes.  In  other  cases,  it  is  caused  by  near  work,  and 
this  is  the  most  frequent  in  the  two  divisions  of  asthenopia.  There 
are  concurrent  signs  of  congestion  of  the  brain  and  spinal  cord, 
such  as  dizziness,  a  sense  of  fulness  and  oppression,  slight  numbness 
of  the  upper  extremities,  tenderness  over  the  spinous  processes, 
etc. 


HENRY  D.  NOYES,  M.  D.  45 

6th.  A  symptom,  correlated  to  headache  is  nausea;  noted  in 
four  cases.  They  were  instances  of  both  refractive  and  muscular 
errors. 

7th.  Intolerance  of  light  varies  in  every  degree.  Extreme 
cases  are  apt  to  be  adjudged  to  have  acute  retinitis  and  grave  vatio- 
cinations  are  given.  He  details  several  cases  of  intense  photo- 
phobia. He  had  had  six  with  twitching  of  lids,  seven  facial  spasms, 
and  eight  vertigo. 

8th.  Irregular  muscular  action  in  the  muscles  of  the  face. 
Sometimes,  the  ocular  disability  was  found  in  ammetropia,  and 
sometimes  muscular.  The  ocular  disabilities  were  relieved  but 
the  nervous  spasms  continued.  He  had  not  been  able  to  discover 
any  casual  connection  between  asthenopia  and  chorea. 

9th.  Strabismus  convergens,  as  one  of  the  symptoms  of  asthen- 
opia, may  be  considered  illogical,  because  it  is  commonly  a  device 
in  which  the  painful  action  is  avoided.  The  hypermetropic,  who 
squints,  voluntarily  thereby  uses  his  eyes  without  fatigue,  but  if 
he  does  not  squint  he  speedily  becomes  tired.  He  finds  seven 
cases  of  strabismus  convergens  with  myopia. 

10th.  Twice  I  find  it  noted  that  there  were  attacks  of  total 
darkness,   lasting   but  a   few   minutes. 

11th.  Objective  examination  interiorily,  showed,  almost  as  a 
matter  of  course,  there  was  hyperemia  of  the  optic  nerve  and 
retina.  There  is  a  state  of  the  nerve  which  could  be  pounced  upon 
by  "cebro  oscopiats"  as  evidence  of  head  trouble,  unless  there  are 
signs  of  infiltration  and  swelling  and  opacity  of  the  nerve,  the  fact 
of  hyperemia  counts  for  very  little. 

12th.  The  acuity  of  vision  in  asthenopia  may  be  perfect  or  im- 
perfect: does  not  exclude  refractive  error,  nor  in  imperfect  vision 
does  not  always  admit  of  full  correction. 

Etiology. — As  to  the  etiology  of  asthenopia,  he  says,  old  writers 
dwelt  upon  the  influence  of  impaired  health  exerted  upon  the  work- 
ing powers  of  the  eyes  and  this  must  be  recognized  in  some  cases 
as  the  essential  and  only  cause,  but  in  a  great  majority  of  cases, 
the  ill  health  is  but  the  exciting,  and  not  the  essential  cause.  The 
controlling  cause  lies  in  local  disturbances;  of  these  the  larger  part 
is  refraction  and  muscular  errors;  they  are  found  in  conjunction; 
there  are  cases,  however,  of  pure  refraction  and  also  cases  of  pure 
muscular  trouble;  a  few  paresis  of  accommodation.  Another 
class   of  cases   is  found   with  irritation  of  the  cervical  part  of  the 


46  HAZEN'S   NEW    FINDINGS 

spinal  cord  and  base  of  the  brain.  Another  subdivision,  the  sequel 
of  nasal  catarrh.  In  an  immense  majority  of  cases  of  asthenopia 
an  adequate  and  intelligent  cause  can  be  found. 

I  have  found  hypermetropic  astigmatism  in  small  degrees,  of 
importance  to  correct. 

Muscular. — In  muscular  trouble,  I  have  been  helped  out  of 
perplexity  by  finding  small  deficiences  in  the  externi  or  in  the 
movement  of  the  globe  in  a  vertical  direction,  in  maintaining  an 
extreme  position;  so  too,  the  fact  that  there  is  a  rotary  motion  on 
the  horizontal  movement,  unsteady  and  jerky.  There  need  be 
nothing  like  nastigmus  or  diplopia  and  there  may  or  may  not  be 
refractive  errors. 

Hyperaesthesia. — He  believes  that  a  few  cases  of  hyperesthesia 
of  the  retina  are  too  often  assigned  as  the  primary  lesion  in  undue 
sensibility  of  the  retina,  or  the  neuralgia  of  the  nerves  of  sensation 
are  used  to  cover  up  imperfect  examinations.  The  correction  of 
small  errors  is  not  always  attended  with  happy  results.  Repose 
is  needful,  sometimes  entire  discontinuance  of  work  for  a  time.  I 
very  rarely  give  this  advice;  the  moral  effect  is  not  good. 

All  oculists  practice  the  advice  of  Dr.  Dyer.  It  takes  from  one 
to  six  months  to  cure,  and  very  many  have  been  cured  by  this  pro- 
cess. 

Muscular  Asthenopia. — The  muscles  recti  interni  are  so  fre- 
quently the  pair  at  fault,  that  the  occurrence  of  weakness  on  other 
muscles  is  liable  to  be  overlooked. 

Next,  in  order  of  frequency,  come  cases  in  which  all  the  muscles 
are  deficient.  Next  come  the  recti  externi,  and  lastly,  cases  in 
which  the  movements  of  the  eyes,  up  and  down,  are  irregular — 
excluding  nastigmus. 

Tests. — He  uses  Graefe's  test  for  insufficiency,  but  prefers  a 
white  dot  on  a  black  surface  to  the  dot  and  line.  Of  late  had  been 
taking  the  power  of  adduction  and  abduction  at  20  feet,  it  being 
more  reliable  than  in  the  association  with  accommodation.  Among 
the  emmetropic,  the  muscular  power  is  much  below  standard  and 
varies  as  the  tone  of  the  general  health. 

"It  has  been  my  observation  that  very  few  persons  can  get  along 
comfortably  with  less  than  20°  adduction  for  20  feet  distance  and 
4°  to  6°  abduction.  "These  cases  have  been  little  regarded, 
because  the  share  which  the  muscles  contribute  to  the  dis- 
comfort   of     myopes,    has     absorbed     the    ophthalmic     attention." 


HENRY  D.  NOYES,  M.  D.  47 

Association  of  Accommodative  and  Muscular  Asthenopia. — 
As  a  rule,  patients  with  hypermetropia  suffer  from  accommodative 
asthenopia  alone,  but  the  combination  with  muscular  asthenopia 
is  not  impossible.  The  addition  of  a  glass  to  the  eye  changes  the 
muscular  equilibrium  and  usually  developes  a  higher  degree  of 
insufficiency  than  without  glass,  but  the  inaptitude  may  soon  dis- 
appear." 

Spasm  of  Accommodation. — He  gives  a  series  of  cases  of  spasm  of 
accommodation,  provoked  by  weakness  of  the  interni,  associated 
with  Myopia  and  Astigmatism.  He  also  gives  a  number  of  cases, 
whose  external  recti  are  at  fault,  with  asthenopia  with  no  converg- 
ing strabismus;  some  with  pain,  some  intolerance  of  light,  others 
conjunctivitis.  He  found  a  few  cases  where  the  failure  of  equilib- 
rium was  from  verticals.  His  means  of  diagnosis  was  not  that 
which  we  have.  He  reports  a  large  number  of  cases  where  all  the 
muscles  were  enfeebled.  Half  were  emmetropic.  Fixation  and 
movement  showed  tremor,  and  they  exhibited  the  symptoms  of 
asthenopia  in  an  exquisite  degree.  Some  had  a  horror  of  looking 
at  objects,  and  mind  especially  morbid.  Some  were  emmetropic; 
some  had  equilibrium. 

Dr.  Noyes  finds,  that  out  of  227  cases  of  muscular  asthenopia 
172  were  of  the  recti  interni;  24  of  all  the  muscles;  16  of  recti  externi; 
15  of  oblique,  supra  and  infra. 

There  was  insufficiency  of  recti  interni  with  60  of  E.;  30  of  H.;  56 
of  M.;  and  26  of  astigmatism. 

TREATISE  ON  THE   DISEASES  OF  THE  EYE  (WOOD'S 
LIBRARY).     1881. 

A   TEXT   BOOK   ON   THE    DISEASES    OF   THE   EYE.     1890. 

Asthenopia. — In  Dr.  Noyes'  "Diseases  of  the  Eye" — Woods' 
Library  Edition  (18S1)  he  uses  the  word  asthenopia,  but  he  does 
not  head  a  chapter  with  it  or  make  it  a  distinct  disease,  and  the 
word  does  not  appear  under  Accommodation,  but  it  is  made  promi- 
nent in  his  later  work,  "Diseases  of  the  Eye"  (1890)  where  he  devotes 
20  pages  to  it,  in  two  of  which  Accommodative  Asthenopia  is  des- 
cribed, and  in  the  subject  of  refraction  it  is  mentioned,  and  not 
many  of  the  symptoms   are  ascribed   to  the  ciliary   muscle. 

Causes. — Among  the  causes  of  asthenopia,  he  says,  "refractive 
errors — especially  myopia  which  inclines  to  weakness  of  adduction, 
and  hyperopia  which  inclines  to  weakness  of  abduction,  and  astig- 


48  HAZEN'S  NEW  FINDINGS 

autism,  arc  frequent  and  obvious  causes.  There  may,  however, 
be  small  errors,  too  trifling  to  account  for  the  asthenopia,  and  the 
persons  enjoy  good  health  and  good  use  of  eyes  until,  without 
explanation,  an  acute  breakdown  occurs.  "The  person  may  be 
ot  exceptional  vigor,  and  not  have  attempted  more  eye  work  than 
may  be  justly  called  reasonable,  yet  have  severe  pain  in  the  eyes 
and  head,  sometimes  vertigo  and  a  sense  of  oppression  and  much 
ocular  irritation."  "The  refractive  error  may  be  very  small,  and 
the  only  statement  to  be  made  is,  that  certain  muscles,  say  the 
externi  or  the  interni,  are  intrinsically  weak.  Frequently,  operative 
causes  are,  depreciation  of  general  health  by  chronic  or  acute 
diseases,  pressure  on  the  nerve  twigs  by  inflammation,  or  thicken- 
ing of  their  sheath,  by  growths,  by  injuries,  or  by  congenital  dis- 
orders; heredity  is  not  infrequent.  Overtaxation  of  the  eyes  is 
the  important  factor,  and  is  brought  about  by  reading  on  railway 
trains  and  in  carriages;  by  reading  when  lying  down,  which  con- 
valescents and  chronic  invalids  often  find  out  too  late,  they  should 
not  do,  by  attempting  difficult  work,  such  as  embroidery,  sewing 
on  black,  fine  painting,  decoration  of  china,  etc.;  bending  over  work 
and  bringing  it  too  near  the  eyes;  by  the  study  of  languages  whose 
text  is  intricate,  such  as  Greek,  German,  Hebrew,  etc.  Want 
of  vigor,  whether  from  congenital  conditions  of  health;  by  too  rapid 
growth,  by  malaria,  by  any  debilitating  causes,  by  shock,  grief, 
etc. — all  are  to  be  duly  considered — especially  too,  all  forms  of 
uterine  diseases,  hemorrhage,  fevers,  chronic  anaemia,  instigate 
muscular  asthenopia.  It  will  often  happen  that  the  depressing 
agencies  mentioned  are  simply  exciting  causes  of  a  disorder,  whose 
real  progenitor  is  an  essential  muscular  weakness,  which  may  long 
have  been  latent,  but  is  now  made  potential." 

Muscular  Insufficiency. — "It  is  important  to  make  a  dis- 
tinction in  cases  of  muscular  insufficiency  and  those  which  are 
purely  local,  and  those  in  which  the  defect  is  associated  with  gen- 
eral ill  health.  Symptoms  of  eye  trouble  may  be  simply  the  effect 
of  remote  disorders,  on  the  other  hand,  eye  defects  can  excite 
remote  reflex  troubles,  and  these  quite  disappear  when  the  eye 
defects  are  corrected." 

Under  Muscular  Asthenopia,  he  details  most  of  the  symptoms 
that  are  so  graphically  described  by  some  writers,  under  eye  strain. 

"Cases    of   apparent    congestion    of   the    base   of   the    brain,    and 

enderness    over    the    middle    and    upper    cervical    vertebrae."     To 

the  previous  enumeration  of  symptoms  in  the  report  at  the  Congress, 

he   mentions   the   relief  obtained   by  pressing  the  eye   balls.     Pain 


HENRY  D.  NO  YES,  M.  D.  49 

in  using  or  fixing  the  eyes  is  the  conspicuous  symptom.  This 
appears  in  all  kinds  of  near  work,  reading,  writing,  etc.;  it  may 
also  exist  in  distant  vision,  in  looking  at  a  crowd,  or  at  a  stage  in 
a  theater,  looking  out  of  a  carriage  or  from  the  window  of  a  railway 
car,  etc.  There  may  be  great  photophobia.  Pain  is  generally 
in  the  eyeball,  but  is  often  temporal,  frontal,  occipital  or  at  vertex. 
In  truth,  not  a  small  percentage  of  obstinate  headaches,  "especially 
ache  on  first  awaking  from  sleep  in  the  morning."  Dizziness,  and 
when  the  general  health  is  feeble,  or  the  subject  neurotic;  we  may 
have  the  most  erratic  and  intense  remote  symptoms;  aphonia, 
palpitation  of  the  heart,  pain  in  the  ovaries,  diarrhoea,  rectal  irri- 
tation, etc.  He  here  speaks  cautiously  of  the  hysteria,  chorea, 
epilepsy  and  says,  "I  cannot  deny  that,  in  a  few  cases,  eye  strain 
may  have  been  demonstrated  to  be  an  exciting  cause  or  occasion, 
but  there  has  been  behind  it  a  deep  lesion  of  the  general  nerve 
system. " 

Spasms  of  Accommodation. — Under  Spasms  of  Accommodation, 
(Wood's  Library  Edition  5)  "  It  will  very  likely  be  found  that  the 
extrinsic  muscles  of  the  eye  are  also  weak,  they  belong  in  the  same 
reduced  state  as  the  ciliary  muscle."  "Moreover,  the  supposition 
of  spasm  is  not  to  be  excluded  because  of  general  debility.  It 
also  appears,  together  with  other  spasmodic  afflictions,  such  as 
blepharospasm  and  nastigmus  and  again  in  cases  of  hyperesthesia 
retinae." 

"Spasms  of  Accommodation  accompany  many  functional  and 
refractive  disorders  of  the  eye."  "It  is  the  immediate  cause  of 
the  discomfort  of  the  great  body  of  workers  upon  small  objects, 
who  complain  of  eye  troubles."  "In  my  view,  many  cases  of  Mus- 
cular Asthenopia  are  not  evidences  so  much  of  the  defective  power 
of  certain  muscles,  as  of  continued  and  excessive  action  or  spasms 
of  opposing  and  dominating  muscles.  Only  in  this  view,  can  many 
cases  of  recovery  by  spasms  and  by  slight  tenotomies,  be  accounted 
for." 

Objective  Symptoms. — Under  Objective  Symptoms,  after 
observation  of  the  manner  in  which  eyes  behave  under  the  test, 
with  card  first  over  one,  then  over  the  other  eye,  as  to  tremulousness 
and  deviation  from  the  median  line,  and  carrying  the  object 
looked  at  close  to  the  nose,  and  also  their  behavior  in  extreme 
positions  to  the  right  and  to  the  left,  and  pronouncing  these  tests 
only  suggestive,  he  begins  with  the  real  examination,  correction  of 
the  refractive  errors,  visual  acuity."     Next  the  muscular  conditions. 


50  HAZEN'S  NEW  FINDINGS 

Regarding  a  candle  flame  at  6  meters  with  prisms,  he  makes  the  re- 
mark, "that  it  is  decidedly  preferable  to  take  the  muscular  condi- 
tions at  this  remote  point."  Experience  proves  that  the  moderate 
rees  of  Ametropia  do  not  interfere  with  muscular  tests.  Begin- 
ing  with  abduction,  he  uses  a  battery  of  a  series  of  square  prisms, 
one  above  the  other,  with  interval  of  2°,  one  series  with  odd 
numbers  and  another  with  even  numbers,  9  in  each  (prefer- 
ring this  to  the  revolving  double  prism  as  more  reliable  and  less 
misleading)  to  ascertain  capacity  of  the  muscles.  Besides  this, 
'or  one  eye,  one  may  hold  in  the  other  hand  a  5°  interval,  over 
each  eye  for  adduction,  and  when  this  is  exhausted,  place  10° 
over  each  eye  in  spectacle  frames  and  proceed  with  the  bat- 
teries in  front  of  them;  can  thus  attain  to  62°. 

The  strongest  prism  which  can  be  overcome,  that  is  despite  of 
which  the  flame  appears  single,  measures  the  duction  of  that  pair. 
Less  than  5°  abduction  is  pathological.  Adduction  is  made  by 
reversing  the  base  outward,  being  careful  to  avoid  obliquity. 
Adduction  should  reach  25°  to  50°,  but  the  physiological  limit 
is  not  well  defined.  More  than  one  examination  is  necessary  to 
decide  what  may  be  the  patient's  capacity.  Next  put  before 
one  eye  a  5°  or  a  10°  prism  base  [axis]  vertical.  Two  flames 
appear,  which  ought  to  be  perpendicular  to  each  other.  When 
prism  is  over  L.  E.  w7ith  base  upward,  the  lower  image  corresponds 
to  L.  E.  If  this  appears  to  the  left  of  the  other  as  well  as  below, 
the  condition  indicates  homonymous  diplopia  and  weakness  of 
abduction  or  of  the  interni.  If  the  lower  image  goes  to  the  patient's 
right,  this  means  weakness  of  adduction  or  of  the  interni.  The 
prism  placed  so  as  to  bring  the  images  into  a  vertical  line  measures 
the  displacement,  which  Von  Graefe  called  the  insufficiency  of  the 
muscles,  whether  of  the  externi  or  interni.  This  phrase  has  ac- 
quired  this   technical   meaning  and   is,   to  some  extent,    misleading 

He  gives  place  to  Dr.  Stevens'  terms  in  muscular  anomalies. 
He  had  not  found  any  absolute  standard  for  adduction  and  ab- 
duction, nevertheless,  a  certain  ratio  must  not  be  exceeded;  and  for 
distance  for  adduction  36°  to  42°,  abduction,  60°  or  adduction  40° 
to  45°,  and  abduction  70°  which  is  about  6  to  1.  For  near  13 
inches,  adduction  40°  and  abduction  20°  suffices  for  comfort. 

Examination  at  working  distance.  Instead  of  Von  Graefe's 
dot  and  line  test,  he  uses  a  white  dot  on  a  black  surface  placed  on  a 
carrier  on  a  central  stem.  Near  the  eye  is  a  box  containing  three 
cells  before  each  eye,  into  which  square  lenses  can  be  dropped, 
which  is  more  convenient  than  the  trial  frame.    Sometimes  a  patient 


HENRY  D.  NOYES,  M.  D.  51 

cannot  put  forth  his  real  energy  when  looking  into  an  apparatus. 
Let  him  make  a  few  trials  without — holding  the  prisms  in  one  hand 
and  the  test  card  in  the  other.  Beginning  with  Von  Grade's  equil- 
ibrium test,  place  a  10°  with  base  (axis)  vertical.  Jf  images  do 
not  stand  vertically  above  one  another,  there  is  deviation  in  the 
sense  of  abduction.  When  about  5°  only,  this  cannot  be  called 
abnormal,  and  directs  suspicion  upon  the  externi.  Next  try 
the  abduction  and  the  adduction  suitably  placed.  Great 
diversities  will  appear,  according  to  conditions  of  refraction;  espec- 
ially will  weakness  of  adduction  appear  with  myopia.  On  the 
other  hand,  abduction  will  more  frequently  be  found  in  emmetro- 
pia  hypermetropia,  and  astigmatism.  Spasms  of  accommodation 
may  be  detected  by  slipping  into  the  holder  a  5°  prism  combined 
with  a  plus  3.  D.  base  inward  before  each  eye ;  placing  Xo.  1 
Snellen  at  13  inches;  if  not  read  by  emmetropes  until  it  approaches 
to  9  inches,  spasm  may  be  inferred.  With  myopes,  spasm  sum- 
cent  to  vitiate  the  test  is  not  common,  while  writh  other  ametropes 
proper  corrections  will  be  made. 

A  small  number  of  cases  exhibit  symptoms  of  muscular  asthenopia, 
which  do  not  betray  any  notable  fault  of  the  externi  or  the  interni, 
nor,  if  there  be  errors  of  refraction  does  its  correction  remove  the 
symptoms.  In  such,  search  for  errors  in  action  of  the  muscles, 
which  move  the  globe  up  and  down.  With  correction  of  refraction 
on,  light  at  20  feet,  use  a  prism  base  inward  of  10°  or  15°  (be 
careful  that  the  axis  is  perfectly  horizontal)  If  the  two  images 
are  not  on  a  horizontal  line,  inquire  which  is  the  higher.  The 
images  are  homonymous  images  because  the  visual  lines  are  rela- 
tively convergent,  and  if  the  left  is  above  the  other  the  fault  is  in 
the  L.  E.  and  vice  versa.  If  there  is  no  vertical  error,  try  what  power 
the  patient  possesses  for  overcoming  prisms  with  vertical  axes. 
Begin  with  one  degree  and  go  up  until  the  limit  is  reached.  I  have 
found  them  able  to  overcome  3°  to  8°  with  no  apparent  de- 
viation of  visual  lines.  If  a  prism  of  3°,  with  the  base  up  be- 
fore the  eye,  is  easily  overcome,  it  should  cause  very  wide  dip- 
lopia if  its  base  is  reversed;  by  thus  testing  each  eye,  we  may 
succeed  in  determining  which  is  at  fau.t.  For  persons,  who  do  not 
habitually  and  invariably  practice  binocular  vision,  as  in  some 
myopes  and  in  cases  of  great  anisometropia,  etc.;  this  fault  of  ver- 
tical displacement  of  one  visual  axis,  is  exceedingly  common,  and 
does  not  occasion  asthenopic  symptoms.  For  them  it  is  difficult  to 
recognize  double  images,  and  if  they  do  catch  them,  it  may  be  only 
for  an  instant,  even  when  they  are  brought  into  close  contiguity. 
When  the  candle  flame  is  seen  obliquely,  it  indicates  a  fault  with 


52  HAZEN'S  NEW  FINDINGS 

one  of  the  oblique  muscles.      We  have  six  general  muscular  weak- 
nesses for  all  distances. 

\Yc  have  symptoms  of  muscular  asthenopia  most  frequently 
in  cases  where  muscular  groups  are  not  properly  balanced  or  pro- 
portioned. We  may  also  have  it  when  there  is  debility  of  the  whole 
muscular  apparatus  without  special  disproportion  among  the  oppos- 
ing groups.  It  is  not,  however,  an  invariable  rule,  that  general 
weakness  of  the  eye  muscles,  of  necessity,causes  asthenopia.  A 
large  margin  must  be  allowed  for  what  may  be  called  nervous 
excitability  or  activity.  Those  of  quick,  eager  and  vivid  per- 
ceptions, whose  mental  processes  are  always  lively  and  ready, 
are  the  persons  most  liable  to  complain.  The  torpid  or  deliberate 
persons  are  less  often  sufferers  from  muscular  asthenopia.  The 
young  often  suffer  from  this   trouble. 


Dr.  Landolt  of  Paris,  France  has  figured  largely  in 
contributions  to  American  Ophthalmic  literature  during 
the  last  decade.  He  comes  nearer  to  the  views  of  Dr. 
Noyes  of  New  York  than  other  authors  on  the  subject, 
in  his  conception  of  the  relation  of  the  focal  apparatus 
and  the  motor  apparatus,  but  did  not  reach  Dr.  Noyes' 
practical  treatment  of  the  muscular  anomalies,  which 
he  found  so  abundant. 

1886. 

E.  LANDOLT,  M.  D.,  PARIS,  FRANCE. 

THE  REFRACTION  AND  ACCOMMODATION  OF  THE  EYE. 

Translated  by 

C.  M.  CULVER,  M.  A.,  M.  D. 

1900. 

E.  LANDOLT,  M.  D.,  PARIS,  FRANCE. 

ANOMALIES   OF  THE  MOTOR  APPARATUS   OF  THE  EYE. 
IN  SYSTEM  OF  THE  DISEASES  OF  THE  EYE.  VOL.  IV. 

Translated  by 

C.  M.  CULVER,  M.  A.,  M.  D. 

Ophthalmic  Surgeon  to  the  Albany  Orphan  Asylum,  Albany ,   N.    Y. 

REFRACTION  AND  ACCOMMODATION. 

He  explains  the  effect  of  glasses  on  accommodation  and  conver- 
gence as  follows: 

Convex  glasses  modify  the  relations  between  accommodation 
and  convergence.  A  sudden  exclusion  of  accommodation  in  order 
to  fix  the  near  object  binocularly,  he  is  obliged  to  make  a  consider- 


54  HAZEN'S    NEW    FINDINGS 

able  effort  at  convergence,  while  the  accommodation  must  be  totally 
released.  At  first  the  object  is  seen  with  crossed  diplopia,  because 
"the  sudden  exclusion  of  the  accommodation  disposes  the  eyes 
to  assume  a  parallel  direction,  or  at  least  renders  convergence 
difficult."  "They  diverge  therefore,  relatively  to  the  position 
of  the  object.  Even  when  one  has  succeeded  in  uniting  the  double 
images,  a  certain  disagreeable  feeling  often  persists  in  the  forehead 
and  eyes  and  proves  that  the  latter  perform  only  with  difficult}', 
this   unusual  and   anti-physiological  function." 

Now'  since  the  elasticity  of  the  crystalline  lens  is  diminished 
throughout  life,  the  accommodative  effort  ought  to  increase  pro- 
portionally, in  order  to  produce  the  same  number  of  dioptries, 
and,  inasmuch  as  the  amplitude  of  convergence,  essentially  depend- 
ent upon  the  strength  of  the  muscles,  does  not  diminish  with  the 
accommodation,  but  remains  nearly  stationary,  the  individual  is 
forced  to  vary,  in  a  physiological  state,  the  effort  of  accommodation, 
which  he  associates  with  a  given  effort  of  convergence.  "The  3 
dioptries  of  accommodation,  which  an  emmetrope  must  have, 
when  fixing  an  object  33  C.  M.  distant,  will  require  from  him  a 
much  greater  muscular  effort  at  the  age  of  forty  than  at  the  age 
of  twenty  years,  while  the  effort  of  convergence  will  remain  the 
same — 3  meter  angles.  The  difference  is  still  more  perceptible 
in  the  cases  of  hyperopes,  especially  of  the  medium  or  high  degree; 
in  the  defect,  static  refraction  of  itself,  determines  a  branch  of  the 
equilibrium  between  the  two  functions."  "Convex  glasses  render 
inestimable  service  by  relieving  the  accommodative  muscle  of  a 
quota  of  its  work  by  establishing  between  convergence  and  accom- 
modation the  relation  most  agreeable  to  the  individual.  Convex 
lenses  can  also  exercise  a  direct  influence  upon  convergence,  by 
regarding  them  as  two  prisms  with  their  bases  joined.  "An  eye 
looking  through  a  convex  glass  will  see  objects  in  their  real  position, 
only  when  looking  along  the  axis  of  the  lens,  while  they  will  appear 
displaced  along  the  periphery  of  the  glass  on  the  side  "through 
which  the  eye  looks,  when  its  gaze  is  directed  away  from  the  center, 
and  they  will  appear  displaced  toward  the  periphery  of  the  glass 
exactly  as  if  they  were  seen  through  a  prism."  With  a  pair  of  specta- 
cles for  distance,  when  they  look  through  the  center,  the  object 
is  not  deflected,  but  if  used  for  near  visions  the  prismatic  action  is 
apparent,  for  on  converging  the  eyes,  the  eyes  look  through  a  por- 
tion of  the  lens  to  the  apices  toward  the  nose  and,  in  order  to  see 
without  diplopia,  the  prism  effect  has  to  be  overcome  by  an  extra 
effort,  and  if  the  muscles  are  somewhat  weak,  it  makes  itself  felt 


E.   LANDOLT,    M.   D.  55 

even  in  lower  numbers.  "From  four  dioptrics  on,  their  influence 
on  convergence  ought  never  to  he  disregarded."  In  afakia  the 
trouble  is  common.  We  must  confess  that  our  knowledge,  as  re- 
gards muscular  asthenopia,  and  insufficiency  of  convergence  is 
still  in  its  infancy.  The  observation  of  the  results  of  operations 
with  a  view  to  cure  it,  have  been  neither  numerous  nor  in  accord 
with  each  other. 

Insufficiency. — "Insufficiency  of  the  power  of  convereence  is 
quite  a  wide  spread  affection  and  a  frequent  cause  of  asthenopia. 
It  is  not  by  any  means  peculiar  to  myopes  only,  even  if  they  do, 
from  necessity,  at  a  near  point,  suffer  more  from  it  than  others, 
and  are,  on  account  of  the  conformation  of  the  eyes,  more  inclined 
to  it."  He  distinguishes  two  forms — 1st.  "Muscular  asthenopia 
in  the  true  sense  of  the  word,  depending  upon  the  absolute  or  rota- 
tive weakness  of  the  adduction  or  upon  their  insertion."  "The 
second  has  its  origin  in  the  central  organ,  and  depends  upon  a  dis- 
turbance of  the  innervation  or  upon  the  weakness  .of  the  power 
of  fusion."  "The  excursions  of  the  eyes,  the  monocular  fields 
of  fixation  and  the  associated  movements,  may,  with  all  this,  be 
quite  normal,  while  the  amplitude  of  convergence  is  much  reduced, 
even,  at  times,  equal  to  zero.  With  a  negative  convergence  or  di- 
vergence, where  spontaneous  binocular  vision  does  not  exist,  vision 
at  a  near  point"  can  only  be  accomplished  with  the  aid  of  abduct- 
ing prisms.  In  all  cases  where  the  positive  convergence  does  not 
reach  nine  meter  angles,  asthenopic  troubles  may  develop,  when 
the  eyes  are  not  used  for  near  vision.  The  ideal  correction  would  be 
realized  by  a  lens  large  enough,  that  its  periphery  would  reach 
over  both  eyes,  or  better,  by  cutting  out  the  periphery,  which 
would  thus  impinge  over  each  eye  for  insertion  into  spectacles. 
The  prismatic  effect  of  spherical  glasses  also  affects  the  vertical 
meridians — the   position  as  to  the  base  line  is  important. 

Just  as  in  the  case  of  convex  lenses,  concave  ones  act  as  prisms 
if  one  does  not  look  through  their  optical  center.  The  lens  being 
thinner  in  the  center  than  at  the  periphery,  the  prism  effect  is  opposite 
to  that  of  the  convex  lenses.  The  prism  effect,  when  the  lines  of 
fixation  pass  externally  to  the  axes,  will  increase  the  effect  of  con- 
vergence (adducting  prisms)  the  object  being  deflected  outward, 
and  the  eye  in  correcting  it,  converges  to  get  the  image  on  the  fovea 
centralis.  On  the  other  hand,  when  the  eyes  look  through  the  inner 
halves  of  concave  glasses,  the  latter  will  act  like  prisms  with  apices 


56  HAZEN'S   NEW   FINDINGS 

turned   toward    the   temples.      Thus    it    is   that   the   prismatic   effect 
of  concave  lenses,  by  decentcring,  may  render  real  service. 

When  the  insufficiency  of  convergence  has  resisted  hygienic 
measures,  general  strengthening  treatment  aids  in  gaining  repose  of 
the  eyes,  and  when  it  is  too  great  to  be  corrected  by  optical  means, 
we  may  think  of  remedying  it  in  a  surgical  way. 

For  paresis  of  accommodation,  there  is  constitutional  treatment, 
electricity,  and   the  fitting  of  lenses. 

Treatment. — Orthoptic  training  consists  in  the  use  of  a  "Wheat- 
stone's  Stereoscope."  Upon  the  resistance  of  these  methods, 
tenotomy  of  both  external  recti,  advancement  of  the  interni,  or 
even  a  combination  of  both  these  operations  is  explained.  In  cases 
of  "neurasthenic  insufficiency,"  when  amplitude  of  convergence 
is  very  narrow,"  we  ought  to  be  guarded  in  operating  as  well  as 
in  making  our  prognosis."  An  exercise  is  given  in  which  the  patient 
is  seated,  at  least  5  meters  from  a  lighted  candle  and  directed  to 
turn  the  head  to  the  point,  wrhere  there  is  a  tendency  of  the  lights 
to  separate  and  he  is  directed  to  keep  them  fused.  "The  patient 
will,  in  this  way,  succeed  in  extending  the  domain  of  single  binoc- 
ular vision"  after  some  weeks  or  months.  Prisms  may  have  to  be 
resorted  to. 

"When  insufficiency  of  the  adductors  has  given  way  to  a  true 
divergent  strabismus,  and  when  the  latter  is  still  periodic,  it  may 
sometimes  be  remedied  by  prismatic  and  concave  glasses,  but  such 
cases  are  very  rare.  The  divergent  strabismus  which  we  meet 
with  in  practice  has  ,long  since,  far  exceeded  the  degrees  that  are 
corrigible  by  optical  means,."  The  surgical  treatment  is  indeed, 
the  only  efficacious  one  in  high  degrees  of  insufficiency  of  conver- 
gence,  and    with    all    the    more    reason,    in   divergent   strabismus. 

ANOMALIES   OF  THE  MOTOR  APPARATUS   OF  THE  EYE, 
IN  SYSTEM  OF  DISEASES  OF  THE  EYE. 

After  consideration  of  the  ocular  muscles,  one  by  one,  with 
reference  to  the  movements  of  the  globe  and  the  phenomena  which 
result  from  the  paralysis  of  these  muscles,  he  devotes  a  section  to 
-iXon-paralytic  Strabismus." 

A  correct  notion  of  the  ocular  movements  "will  be  had  by  con- 
sidering all  the  muscles,  as  together  forming  one  motor  apparatus." 
It  can  be  seen  that  "each  movement,  given  to  the  eye,  encounters 
an  opposite  regulating  movement."     "There  is  no  direction  that  the 


E.  LANDOLT,  M.  D.  57 

eye  cannot  easily  take,  and  in  which  it  cannot  remain  without 
fatigue."  The  mechanism  is  more  marvelous,  "when  combined 
movements  of  the  two  eyes  are  considered."  Binocular  vision 
requires  that  the  two  eyes  be  directed  simultaneously  toward  the 
object  looked  at,  so  that  it  may  fall  on  the  fovea  centralis  of  each 
eye,  when  the  objects  are  fused  into  a  single  one.  The  impression 
is  thus  made  vivid  and  a  certain  impression  of  distance  and  relief 
is  given  to  it.  The  eyes  diverge  in  a  state  of  rest,  but  without  an 
appreciable  difference  in  height.  Convergence  is  not  an  act  among 
the  lower  mammals.  When  both  eyes  are  not  simultaneously 
directed  toward  the  point  to  which  the  possessor  directs  his  atten- 
tion, strabismus  is  present.  It  is  association  between  accommoda- 
tion and  convergence  which  can  impress  a  proper  direction  upon 
an  eye  which  is  not  fixing.  If  this  association  is  not  present  the 
eye  deviates,  but  will  not,  however,  abandon  the  level  of  its  fellow. 
Now,  paralytic  strabismus,  sursum  or  dorsum  vergins,  is  very  rare, 
and  never  attains  a  degree  comparable  to  that  with  which  one 
usually  meets  in  lateral  strabismus.  Unless  muscular  paralysis 
be  present,  one  eye  never  moves  alone  but  the  second  eye  takes  an 
active  part  in  the  motion  and  there  is  no  divergence  of  one  eye,  as 
in  paralysis  of  the  internal  rectus  or  convergence  of  one  eye,  as  in 
paralysis  of  the  abducens  but  there  is  divergence  or  convergence 
between  the  two  eyes  in  the  same  degree.  One  eye  fixes  and  the 
other  eye  takes  position  out  of  line,  and  this  gives  the  appearance 
of  a  monocular  deviation.  The  expression  correctly  made,  would 
be — "the  eyes  diverge  or  converge — the  right  eye  performing  the 
fixation." 

Strabismus. — "Strabismus  is  not  always  manifest.  In  its 
early  stages  especially,  it  sometimes  remains  latent,  and  shows 
itself  under  conditions  of  fatigue  of  the  eyes  or  body;  under  influen- 
ces of  emotion  or  when  binocular  vision  is  suppressed  by  the  exclu- 
sion of  one  eye."  "When  the  vision  of  each  eye  is  good,  strabismus 
often  passes  from  one  eye  to  the  other,"  the  eyes  alternating  in 
fixing  and  yet  do  not  see  double.  Generally,  by  using  red  glass 
over  one  eye,  the  patient  can  be  made  to  see  two  images.  By 
provoking  diplopia  in  the  vertical  meridian  by  means  of  a  prism 
(base  down)  he  may  be  made  to  see  two  images,  but  it  may  be 
difficult  for  him  to  determine  whether  they  are  homonymous  or 
crossed.  In  paralysis  this  is  not  the  case.  "The  image  of  the 
deviating  eye  is  sometimes  systematically  disregarded  by  the 
visual  center."  One  can  discipline  himself  into  the  same  analogous 
condition,   as   in   the   use   of  the  ophthalmoscope    or    microscope — 


58  HAZEN'S   NEW   FINDINGS 

having  both  eyes  open  in  the  use  of  these  instruments,  and  ignoring 
the  image  received  by  the  eye  to  which  he  is  directing  his  attention. 
This  phenomena  is  called,  "suppression  or  exclusion"  of  the  ims 
of  the  deviating  eye. 

REGIONAL  EXCLUSION. — There  is  such  a  thing  as  regional  exclu- 
sion— a  part  of  the  retina  only  in  which  there  is  suppression,  and 
by  imposing  a  prism  of  double  vision,  it  can  be  provoked  and  can 
then  be  measured.  In  the  horizontal  direction  stronger  prisms  are 
required  than  in  the  vertical  direction,  to  accomplish  this.  The 
entire  retina  may  have  exclusion  over  its  whole  surface  and  this  is 
total  exclusion. 

Not  rarely,  a  kind  of  new  indentity  between  the  two  retince  is 
established.  The  part  of  the  retinae  of  the  affected  eye,  which 
receives  the  image  of  the  object,  assumes  the  function  of  the  macula 
and  the  visual  impression  is  fused  with  that  of  the  healthy  eye. 
Weak  prisms  suffice  to  produce  diplopia  in  these  cases  even  when 
prisms  or  mirrors  are  placed  to  throw  the  image  on  the  mascula 
of  the  deviating  eye,  double  images  are  produced. 

The  long  duration  of  strabismus  is  the  cause  of  the  change  in  the 
correspondence  of  the  retina,  and  after  correction  of  the  strabismus, 
the  diplopia  produced  by  the  change,  through  operation,  almost 
always  disappears.  The  stereoscopic  effect  may  be  restored  if 
the  patient  will  patiently  carry  out  the  necessary  exercises. 

NON-PARALYTIC  DIVERGENT  STRABISMUS. 

After  describing  the  different  etiologies,  held  by  authors  in 
regard  to  Convergent  Squint,  Landolt  says,  "Examination  of  the 
field  of  fixation  has  taught  us  the  fact,  already  pointed  out  by  Don- 
ders,  that  the  temporal  excursion  of  both  eyes  is  almost  always 
restricted  in  convergent  strabismus.  "This  defect  in  motility, 
which  is  often  not  very  pronounced  in  recent  cases,  is  the  rule  for 
cases  of  long  standing.  It  is  always  found  in  both  eyes,  and  often 
in  the  same  degree.  Frequently,  it  is  more  developed  in  the  devi- 
ating one  than  in  the  fixing  one."  "Those  who  are  given  to  the 
performance  of  muscular  advancement,  have  abundant  occasion 
to  verify  the  weakness  of  the  external  recti  muscles  in  cases  of  con- 
vergent strabismus.  These  muscles  are  thin  and  flabby,  especially 
in  comparison  with  their  antagonists."  We  have  to  inquire  whether 
it  is  primary  or  secondary.  It  seems  to  us  that  this  defective 
development  of  the  abductors  is  due  to  a  lack  of  use.     The  excur- 


E.  LANDOLT,  M.  D.  59 

sions  of  the  eyes,  before  we  change  directions  of  our  faces,  are  in 
R.  or  L.,  3°  or  4° — elevation  3°,  lowering  5°.  This  shows  that  no 
demand  is  made  at  all  comparable  with  that  made  on  the  internal 
recti  in  convergence. 

Causes  of  Malformation*. — Enumerating  causes  of  malfor- 
mation as  local  changes  in  the  muscle,  (congenital  weakness,  vici 
insertion,  anatomical  shortening)  spasms  due  to  Keratitis,  which 
many  authors  consider  the  cause  of  convergent  as  well  as  divergent 
strabismus,  Landolt  thinks  has  been  exaggerated,  but  does  not 
deny  the  possibiltiy  of  such  malformations,  yet  why  should  the 
ocular  muscles  be  exempt  from  the  infirmities,  which  are  met  with 
in  all  the  other  muscles  of  the  human  body: 

After  reviewing  the  different  authors  as  to  the  cause  of  the  devia- 
tion in  convergent  strabismus,  he  expresses  it  thus,  "By  contract- 
ing too  much,  the  internal  recti  have  become  unable  to  relax  en- 
tirely, or  exaggerated  convergence  becomes  habitual."  Thus, 
on  account  of  secondary  anatomical  changes,  muscles,  which  at 
the  outset  were  normal,  become  altered  in  their  functions. 
"Nothing, "  he  says,  "is  more  difficult  than  to  determine  the  posi- 
tion of  minimum  innervation  of  the  ocular  muscles."  "It  would  be 
of  no  great  advantage  if  we  could."  It  is  the  consequence  of  the 
influence  of  a  number  of  factors,  which  act  upon  the  relative  di- 
rection of  the  eyes." 

"The  inanity  of  the  muscular  theory  of  squint  having  been 
shown  long  ago,  one  hears  it  said,  upon  different  sides,  that  it  has 
been  replaced  by  a  new  theory,  "the  central  or  nervous  theory." 
These  words  have  no  significance  of  themselves.  Donders'  theory 
of  the  intimate  relation  of  convergence  and  accommodation,  in 
their  connection,  in  the  central  nervous  system,  where  the  fusion 
of  the  two  muscular  impressions  takes  place,  in  the  sensation  of 
binocular  vision,  has  the  great  merit  of  its  explanation  here."  In 
the  light  of  more  recent  physiology,  he  says,  "the  attempts  to 
localize  strabismus  in  the  central  organ,  do  not  mean  that  it  is  to 
be  considered  as  a  cerebral  affection,  although,  in  some  general 
diseases,  there  are  changes  in  the  centers  of  innervation.  If  one 
squints  toward  the  nose  without  being  the  victim  of  paralysis  of 
the  abductors,  it  is  because  his  abductors  are  not  held  in  equilibrium 
by  these  muscles — because  the  former  contract  too  much — the  latter 
too  little,  and  since  they  contract  only  under  the  influence  of  a 
nervous  impulse,  it  is  evident,  there  must  be  an  absolute  or  relative 
excess    of   the    innervation    for    convergence.      If'hy,    the    center   of 


60  HAZEN'S  NEW  FINDINGS 

convergence  shows  itself  so  exuberant  in  convergent  strabismus, 
and  why,  in  divergent,  the  center  fails  to  do  its  duty,  is  to  be  ex- 
plained. "Donders  answers  this  question  satisfactorily  in  the 
immense  majority  of  cases  of  strabismus"  —  mentioning  the  occa- 
sional cause  of  its  development,  he  discusses  fixation  at  the  near 
point,  when  they  sometimes  accidently  discover  that  they  can 
secure  distinctness  of  vision  by  sacraficing  the  use  of  one  eye. 
He  gives  instances  of  persons  curing  themselves  of  strabismus  by 
acting  on  the  contrary  muscles  through  the  will. 

Hyperopic,  convergent  strabismus,  generally  commences  by 
being  periodic  or  alternating.  It  is  often,  at  the  outset,  also  rela- 
tive— localizes  itself  in  one  eye,  generally  the  weaker  one. 

Landolt's     Treatment     of     Convergent     Strabismus. 

"When  due  to  defects  of  refraction,  which  necessitates  an  exaggera- 
ted effort  of  accommodation.  Conner's  glasses  are  indicated  and 
mydriatics.  The  necessity  of  correcting  the  vision  of  the  inferior 
eye  by  correcting  the  astigmatism  and  restoring  it  to  visual  power 
by  exercising  it,  and  still  more  important  are  the  exercises,  which 
bring  into  action  both  eyes  simultaneously  for  the  purpose  of  stim- 
ulating or  re-establishing  binocular  vision.  The  principal  cause  of 
strabismus  and  the  greatest  obstacle  to  its  cure,  being  the  absence 
of  binocular  vision — it  is  evident  that  anything,  which  tends  to 
re-establish  the  fusion  of  the  retinal  impression  of  the  two  eyes, 
constitutes  a  valuable  therapeutic  agent  in  the  treatment  of  the 
infirmity.  To  secure  relaxation  of  accommodation,  it  is  necessary 
to  have  recourse  to  Mydriatics.  He  advocates  the  use  of  Javal's 
stereoscope  in  the  fusion  of  images  for  the  cure  of  strabismus. 

Surgical     Treatment     of     Convergent     Strabismus. 

He  advocates  advancement  instead  of  tenotomy.  It  is  best  to 
continue  orthoptric  treatment  for  a  long  time.  The  most  perfect 
surgical  correction  is  not  always  sufficient,  even  if  the  vision  is  good 
in  both  eyes.  The  eyes  have  forgotten — if  they  have  ever  learned — 
to  fuse  the  impression  of  their  foveas. 

In  divergent  strabismus,  the  false  image  is  carried  toward  the 
temple — homonymous — and  treatment  is  required  for  this,  after 
operation. 


E.  LANDOLT,  M.  U.  61 

NON-PARALYTIC    DIVERGENT  STRABISMUS. 

As  a  rule,  the  eyes  diverge  in  complete  repose  considering  the 
divergence  of  the  orbits.  The  function  of  convergence  is  only 
found  in  the  higher  order  of  vertebrates,  diverging  the  more  as 
we  descend  in  the  examination  until  we  find  in  fishes  that  they  are 
90°  to  each  other.  "Convergence  in  man  is  so  intimately 
associated  with  accommodation,  that,  under  normal  circum- 
stances, an  effort  of  accommodation  suffices  to  provoke  a  conver- 
gent movement."  Without  either  of  these,  divergence  almost 
invariably  takes  place,  and  this  explains  why,  an  amblyopic  eye 
deviates  toward  the  temple,  and  why  myopes,  who  exercise  their 
accommodation  much  less  than  emmetropes,  and  hyperopes,  fur- 
nish the  large  majority  of  divergent  strabismus.  The  ellipsoidal 
form  of  the  myopic,  favors  this  position.  In  high  degrees  of  myo- 
pia, from  the  necessity  of  bringing  the  object  so  close  they  are  apt 
to  give  up  convergence,  and  allow  the  eye,  not  used,  to  diverge. 
Binocular  vision  is  not  developed  and  the  visual  impression  is  sup- 
pressed in  the  eye,  not  fixing,  in  order  not  to  be  troubled  with 
double  vision.  Divergence  is  mostly  absolute,  existing  for  all 
directions  of  the  gaze.  This  condition  very  often  occurs  in  cases  of 
myopia  of  less  degree.  The  alteration  of  accommodation  and 
convergence  undergoes  considerable  change  from  that  in  emmetro- 
pia.  He  sees  without  any  effort  at  accommodation,  at  a  distance 
for  which  he  is  obliged  to  use  a  great  amount  of  convergence.  There 
exists  an  insufficiency  of  convergence.  Up  to  5.  D.  of  myopia, 
the  independence  of  convergence  relatively  to  accommodation, 
can  be  estimated,  if  the  amplitude  of  convergence  is  sufficiently 
developed  for  binocular  clear  vision.  If  there  be  added  to  defec- 
tive development,  enfeebled  motor  muscles,  from  debilitating 
illness,  the  individual  will  only  too  promptly  abandon  convergence, 
and  let  the  inferior  eye  turn  out.  "Thus  we  see  that  typical  con- 
vergent strabismus — that  of  Hyperopes — is  an  active — a  spastic 
strabismus."  "Divergent  strabismus  is  an  essentially  passive 
strabismus,  due  to  a  relaxitive  or  a  lack  of  development  of  conver- 
gence." 

"Although  myopia,  for  the  reasons  stated,  furnishes  the  largest 
proportion  of  divergent  squint,  yet  it  is  also  found  in  other  states 
of  refraction."  Any  cause  which  abolishes  binocular  vision  pre- 
disposes to  strabismus.  Divergence  is  found  in  the  position  of  re- 
pose. "It  is  for  this  reason  that  divergence  is  the  rule  in  monoc- 
ular amblyopia  or  amaurosis."  Fixing  with  the  best  eye,  the  devia- 
tion manifests  itself  in  the  amblyopic  one.     "Divergent  strabismus 


62  HAZEN'S   NEW   FINDINGS 

is  a  binocular  strabismus,  just  as  is  convergent  strabismus."  "In 
the  same  way,  as  the  examination  of  the  field  of  fixation  denotes, 
in  convergent  strabismus  of  long  standing,  a  limitation  of  the 
temporal  excursions  of  both  eyes,  so  the  excursions  toward  the 
nasal  side  are  always  found  limited  in  both  eyes,  although  only 
one,  and  always  the  same  one,  is  the  victim  of  divergent  strabismus." 

"This  defect  in  motility  is,  in  both  cases,  and  in  the  majority 
of  instances,  not  the  cause  but  the  consequence  of  strabismus." 
In  divergent  strabismus,  it  is  due  to  a  lack  of  use  of  the  abductor 
muscles,  for  which  convergence  contributes  an  exercise  much  more 
powerful  than  do  the  associated  lateral  movements.  Considering 
that  "there  is  nothing  absolute  in  the  relations  between  accommoda- 
tion and  convergence,"  "one  cannot  admit  a  single  center  of  inner- 
vation as  ruling  them  simultaneously."  "This  independence  of  re- 
lation is  shown  by  the  fact  that  the  amplitude  of  accommodation 
gradually  diminishes,  as  age  advances,  until  it  becomes  nil,  while 
convergence  remains  almost  invariable  during  the  whole  lifetime — 
hence  the  relations  between  the  two  functions  must  be  continually 
modified,  otherwise  binocular  and  distinct  vision  would  not  be 
possible,  even  for  emmetropic  eyes."  "The  individual  must  learn 
how  to  associate  the  same  degree  of  convergence  with  a  greater 
and  greater   (less  and  less)   degree  of  accommodation." 

As  long  as  the  emmetrope  fuses  well  the  visual  impressions  of 
his  two  eyes,  accommodation  causes  him  to  converge  so  correctly 
that  he  directs  even  the  eye  that  has  been  excluded  from  vision, 
toward  the  object  fixed  by  the  other,  but  if  he  loses  the  sight  of  one 
of  the  eyes,  he  learns  equally  well  to  abandon  the  effort  of  conver- 
gence," and  as  the  insufficiency  is  no  more  troublesome  than  when 
he  had  double  vision,  it  is  natural  that  convergence  should  be  almost 
entirely  lost.  It  may  equally  happen  with  hyperopes,  which 
augments  convergence  in  order  to  facilitate  accommodation.  "Not 
all,  however,  have  convergent  strabismus.  Some  of  them,  deprived 
of  binocular  vision,  squint  outward  and  furnish  a  certain  con- 
tingent of  (5  per  cent)  of  divergent  strabismus."  "As  in  conver- 
gent strabismus,  local  circumstances  have  been  given  as  a  cause; 
vicious  insertion,  a  defective  development,  an  insufficient  power 
of  the  abductor  muscles  or  the  excessive  separation  of  the  orbits, 
and  smallness  of  the  angula  gamma." 

Stilling  and  others  say,  "certain  eyes  ought  to  be  predisposed  to 
divergent  strabismus  by  their  position  of  equilibrium,  which  in 
this  case  is  divergence."     "Another  theory  holds  that  it  is  a   pr-i- 


E.  LANDOLT,  M.  D.  63 

mary  lesion  of  the  centers  controlling  the  symmetrical  movements 
of  the  eyes." 

Concomitant  divergent  strabismus,  which  it  is  necessary  to  dis- 
tinguish from  paralytic  strabismus — The  first  is  equality  of  the 
conjugate  movements  of  the  eyes,  and  the  gradual  development  of 
the  deviation,  etc.  There  is  a  well  defined  diplopia  increasing 
in  one  direction  and  diminishing  in  the  other,  leaving  no  doubt 
of  paralysis.  This  diplopia  is  the  most  striking  symptom  of  para- 
lytic strabismus,  but  in  it  there  may  be  amblyopia  in  one  eye? 
which  excludes  diplopia  and  the  certainty  of  diagnosis  is  made  by 
other  symptoms.  In  this  concomitant  divergent  strabismus, 
the  divergence  manifests  itself  only  under  certain  circumstances 
("relative").  On  looking  into  infinity  the  eyes  may  be  in  equilib- 
rium and  they  may  follow  the  object  as  it  is  brought  nearer,  but 
at  a  certain  point  they  stop  converging,  the  eyes  waver  and  if 
brought  still  closer,  one  eye  diverges,  and  double  vision  is  the  con- 
sequence, although  the  patient  may  describe  it  as  confusion.  The 
beginning  of  divergence  or  insufficiency  may  be  accompanied 
with  asthenopia,  headache,  vertigo  and  visual  disturbances.  This 
initial  stage  of  divergent  strabismus  may  endure  for  months  or 
years.  In  myopia  of  high  degree,  especially  with  amblyopia 
in   one   eye,   the   relation   becomes   absolute   strabismus. 

INSUFFICIENCY  OF  CONVERGENCE. 

There  has  been  a  recognition  of  asthenopia  caused  by  insuffi- 
ciency of  the  interni,  but  Krenchel  in  1S73  clearly  established  that 
convergence  must  be  considered  a  function  by  itself,  which  can  be 
altered  without  lesion  of  the  muscles  which  produce  it.  He  and 
others  gave  support  to  it  so  that  insufficiency  of  convergence  is 
now  considered  as  a  well  defined  entity. 

Landolt  here  defines,  "convergence  as  the  faculty  of  directing 
the  two  eyes  toward  the  object  of  fixation,  whether  the  object  be 
situated  at  a  definite  distance  or  infinite,  or  even  beyond  infinity" — 
that  is  to  say,  whether  its  fixation  requires  actual  convergence, 
parallelism  or  divergence."  He  describes  the  system  of  Nagel 
of  the  meter  angle.  He  has  a  method  of  representation  of  maxi- 
mum and  minimum,  both  positive  and  negative.  See  figure.  Eyes 
can  diverge  one  meter  angle  —  about  3.5°,  or  3.5  centimeters. 
The  negative  convergence  is  above  the  zero  line,  and  the  positive 
below  the  line.  The  normal  amount  of  convergence  ought  to  by 
9  M.  a. 


•;l 


HAZEN'S   NEW    FINDINGS 


-  I- 

0- 
+  I- 

2- 


B 


D      E      F 
R 


H      I      K 


8  — 
9 


10- 
11- 
12- 
13- 

14" 


Fig.  1. 


In  figure  Amplitude  is  represented;  the  full  horizontal  line  in- 
dicates zero  or  parallelism;  the  part  above  the  horizontal  line 
represents  the  negative  convergence  and  the  part  below  the  posi- 
tive   convergence. 

In  A  there  is  normal  negative  and  positive.  In  B  there  is  a 
total  of  10  M.  a.  and  yet  there  is  insufficiency  of  convergence — 
that  being  but  7  M.  a. — the  3  M.  a.  are  negative.  In  C  there  is 
the  same  negative  and  less  positive.  In  D  there  is  only  a  little 
short  of  the  positive.  In  E  the  amplitude  is  all  positive.  In  F, 
C  and  K,  convergence  is  all  negative.  His  adduction  does  not 
bring  him  to  his  parallelism. 


E.  LANDOLT,  M.  D.  65 

The  punctum  proximum  represents  the  maximum  of  convergence 
of  which  an  individual  is  capable,  but  he  can  maintain  neither 
accommodation  nor  convergence  more  than  an  instant  at  this 
point.  This  then  is  not  the  distance  at  which  the  individual  can 
work.  He  must  have  a  certain  amount  of  force  in  reserve  for  his 
working  point. 

The  quota  of  convergence  in  reserve  should  be  twice  as  great  as 
the  convergence  required  for  the  work.  To  work  at  3  M.  a.,  there 
should  be  6  M.  a.  in  reserve —  9  M.  a.  in  all.  In  spite  of  the  normal 
amplitude,  convergence  may  be  insufficient  for  exceptionally  near 
work,  and  those  defficient  in  it  will  find  fatigue,  because  there  is 
diminution  of  the  positive  part.  The  negative  has  to  be  expended 
to  get  parallelism  and  the  remainder  of  the  amplitude  the  positive. 
The  punctum  proximum  is  too  far  away  and  convergence  gives  rise 
to  those  symptoms  of  asthenopia,  which  are  encountered  in  the 
early  stages  of  divergent  strabismus — viz.,  the  fatigue  of  the  eyes, 
crossed  diplopia,  pains  in  the  head,  having  their  seat  especially 
in    the   forehead,    vertigo,  and  general  malaise. 

Insufficiency  may  have  a  cause  in  lesion  of  the  brain  or  spinal 
cord — tabes  dorsules  locomotor  ataxia  and  affections  of  the  nervous 
system.  A  different  form  of  insufficiency  is  that  which  accompanies 
neurasthenia.  He  finds  it  as  a  cause  in  women  and  men,  and  that 
in  men  of  s-plendid  and  remarkable  strength — with  two  good  eyes 
but  not  able  to  use  them  at  short  distance.  It  also  accompanies 
anaemia,  the  sequel  of  typhoid  influenza,  accouchement,  etc.  This 
form  he  denomininates  as  central  because  of  lack  of  energy.  In 
those  from  lack  of  use,  as  in  myopia,  divergence  coming  because 
one  of  the  stimulants,  accommodation,  is  lacking.  Although  they 
may  have  amplitude  of  convergence  it.  is  inferior  to  emmetropes' 
and  there  is  excess  of  abduction,  and  lack  of  exercise,  but  there 
is  in  no  wise  a  paralysis. 

As  in  the  case  of  an  equestrian,  who  is  not  in  practice  and  is 
easily  thrown  because  he  cannot  cling  with  his  legs,  the  adductors 
are  weak  and  we  encourage  strengthening  of  the  muscles  by  their 
innervation. 

Convergence  is  defective  because  it  is  not  exercised,  but  he  does 
not  think  this  form  of  convergence  is  of  central  origin,  for  this  term 
is  generally  understood  to  imply  a   material  cerebral  lesion. 

Still  another  form  of  insufficiences  is  where  the  muscles  are  really 
weak,  in  which  the  field  of  fixation  shows  a  limitation  on  the  nasal 


66  HAZEN'S  NEW  FINDINGS 

si.lc.  It  is  the  muscular  insufficiency,  which  gives  rise  to  asthen- 
opia with  or  without  binocular  vision.  The  existence  of  muscular 
insufficiency  has  been  denied,  as  if  the  ocular  muscles  could  not 
become  incompetent  in  their  work,  just  as  in  the  cases  of  other 
muscles.  Thorough  examination  would  dispel  such  theories  and 
prevent  such  statements — notably  the  field  of  fixation. 

There  are  cases  where  the  convergence  is  rudimentary  and  the 
muscles  are  weak,  as  in  myopes,  where  the  excursion  laterally  is 
limited  to  a  very  few  degrees  and  has  no  duration.  This  is  account- 
ed secondary.  There  is  also  a  primary  insufficiency  due  to  con- 
genital defects.  Such  conditions  are  met  with  in  other  muscles, 
wliv  not  the  eve? 


Diagnosis  of   Convergence. 

"To  know  one's  power  of  convergence,  determine  the  distance 
of  the  nearest  point  to  which  one  can  converge,"  and  compare 
with  value  found  in  the  same  way  in  healthy  persons. 

The  Ophthalmo  dynamometer  consists  of  a  cylinder  blackened 
outside,  and  in  which  a  candle  forms  the  light.  There  are  slits 
and  circular  holes,  covered  with  ground  glass,  furnishing  luminous 
apertures.  To  measure,  a  tape  line  is  attached,  which  is  rolled 
up  by  a  spring.  The  tape  is  graduated  in  centimeters  and  meter 
angles.  To  determine  the  maximum  of  convergence,  use  the  luminous 
slit,  one  third  of  a  millimeter  in  breadth  for  fixation,  placing  it  in 
the  median  line.  It  is  then  drawn  up  until  there  is  diplopia  (crossed). 
This  is  the  near  point  of  convergence.  One  eye,  with  a  red  glass, 
will  sometimes  enable  the  patient  to  perceive  the  second  image. 
To  measure  accommodation,  there  are  the  fine  openings  to  let 
the  light  through  small  punctures. 

With  a  maximum  of  9  M.  a.  to  10  M.  a.,  Landolt  says,  "that  he 
has  rarely  met  insufficiency  of  this  function,  among  persons  capable 
of  converging  to  a  point  10  centimeters  distant.  Since  two  thirds 
of  the  convergence  must  be  kept  in  reserve,  9  M.  a.  would  suffice 
for  a  distance  of  33  centimeters.  25  centimeters  4  M.  a.  would 
demand  8  M.  a.,  hence  12  M.  a.  altogether.  This  is  not  rare  but 
less  for  this  point,  he  would  soon  tire.  If,  in  case  of  only  8 
M.  a.  the  work  must  be  removed  further  away,  or  a  frequent  inter- 
val of  rest  is  necessary,  or  asthenopia  follows  after  a  mixing  up  of 
the  objects.  The  parties  often  have  a  distinct  sensation  that  one 
of   the   eyes    has    deviated   outward.      With    some,    the    phenomena 


E.  LANDOLT,  M.  D.  67 

of  insufficiency,  is  a  difficult}'  in  directing  the  gaze  from  one  point 
to  another  where  distances  vary.  These  successful  fixations  are 
not  executed  with  the  facility  of  healthy  exes.  Objects  before 
being  fixed  are  double  or  indistinct,  and  in  the  movement  of  the 
eyes  there  is  a  feeling  of  annoyance.  A  closing  of  the  eyes,  or  a 
gaze  into  the  distance  rests  the  muscles  but  the  fatigue  becomes 
more  intense  and  necessitates  repose.  Asthenopia  increases  to 
such  a  degree  as  to  render  all  work  impossible,  or  a  production 
of  cephalalgia,  hemicrania  nausea,  vertigo,  etc.  A  short  objective 
examination  shows  the  behavior  of  the  eyes;  when  directed  to  a 
near  point,  there  is  a  recoil,  a  withdrawing  from  the  object,  oscilla- 
tion and  at  last  a  divergence.  The  phenomena  will  manifest  itself 
in  only  one  of  the  eyes,  one  fixing  and  the  other  turning  outward. 
This  behavior  will  be  similar  in  all  eyes  as  we  approach  their  maxi- 
mum of  convergence,  but  the  pathological  conditions  will  be  seen 
earlier  in  some,  according  as  the  deficiency  is  developed.  The 
maximum  of  some  cases  is  on  the  negative  side  of  zero,  and  at  a 
distance,  and  the  amount  is  measured  by  abducting  prisms.  \\  e 
are  to  measure  the  excursion  of  the  eyes  by  the  perimeter.  The 
state  of  the  mobility  will  then  be  completed  by  the  determination 
of  the  equilibrium.  The  point  of  absolute  pose,  which  he  proceeds 
to  find  on  the  distance,  is  more  difficult.  The  examination  must 
be  objective.  The  eyes  are  so  mobile,  the  inner  value  of  the  motor 
apparatus  is  both  so  complex  and  so  delicate,  that  even  a  semi- 
conscious thought  suffices  to  modify  their  relative  direction.  Only 
narcosis  or  death  brings  about  an  absolute  relaxation  of  the  ocular 
muscles. 

To  withdraw  the  patient  from  influences  that  would  give  direction 
of  the  eyes.  1st.  At  a  distance  accommodation  is  not  required. 
2nd.  Making  the  images  dissimilar  by  means  of  a  colored  glass 
over  one  eye,  the  tendency  to  fusion  is  less.  3d.  With  prisms  by 
which  insurmountable  diplopia  is  produced  there  is  even  less  ten- 
dency. Some  are  led  into  the  dark  and  then  required  to  open  their 
closed  eyes  and  say,  at  the  moment  of  opening,  whether  the  lu- 
minous object  is  single  or  double,  or  they  take  position  in  an  abso- 
lutely dark  room,  with  their  eyes  open  and  a  light  flashed  at  a  dis- 
tance.    The  Maddox  rod  that  is  mentioned  is  good. 

Landolt  has  most  confidence  in  Yon  Graefe's  method  of  placing 
before  one  eye  a  vertical  prism.  He  does  not  advocate  its  appli- 
cation for  short  distances,  in  which  Yon  Graefe  used  it.  Abduction, 
at  a  distance,  is  the  negative  of  the  amplitude  of  convergence,  and 
1  e  says,  "to  the  same  extent  that  investigation  of  absolute  divergence 


C8  HAZEN'S   NEW  FINDINGS 

18  rational  and  useful,  so  is  the  opposite  attempt  (by  means  of  abduct 
ing  prisms)  devoid  of  sense,  utility  and  accuracy."  He  regards  the 
exercise  of  abduction  and  adduction,"  without  changing  the  accom- 
modation  places    the    patient    in    conditions    of   vision    which 

are  entirely  abnormal/'  These  investigations  of  the  equilibrium 
and  latent  deviations  of  the  eyes,  in  no  wise  inform  us,  either  of 
the  amplitude  of  the  eyes  for  work  or  of  the  nature  of  the  asthenopia." 
He  gets  but  little  in  the  study  of  equilibrium.  Where  there  is 
divergence  there  may  be  no  insufficiency  of  convergence.  The 
tendency  to  diverge  or  converge  gives  us  the  position  the  eyes 
would  take  if  binocular  vision  was  lost. 

He  has  devised  the  Kinothalmoscope,  an  adjustment  made  of 
a  plate  of  glass  with  handle  on  which  he  places  objects,  as  reading, 
upon  which  the  eyes  are  fixed,  and  the  observer,  looking  through 
the  interstices  of  objects,  can  observe  the  behavior  of  the  eyes  in 
doing  so. 

Treatment  of   Insufficiency    of    Convergent    and   of   Diver- 
gent   STRA3ISMUS. 

These  are  so  intimately  related  to  each  other,  that  the  treatment 
of  both  may  be  combined  under  one  head.  The  constitutional 
etiology  is  made  prominent,  physical,  moral,  and  intellectual; 
out  of  door  exercise,  hydrotherapy,  change  of  environment,  travel, 
etc.  The  exercise  of  the  impotent  function,  more  than  anything 
else  will  render  them  service."  He  takes  up  the  controversy  on 
the  exercise  of  the  muscles,  wherein  there  are  directly  opposite 
opinions.  Xoyes  recommended  exercise,  but  Von  Graefe  advised 
the  opposite.  Exercise  would  only  fatigue  and  weaken  them  still 
more,  but  Landolt  sees  that  both  may  be  right  in  different  condi- 
tions. When  the  infirmity  is  ascribed  to  a  lack  of  exercise,  and 
after  surgical  intervention,  the  exercise  is  recommended  on  the  near 
objects.  In  cases  of  commencing  divergence,  when  binocular 
vision  exists,  but  where  one  is  amblyopic  or  amaurotic  these  are 
excluded.  Where  binocular  vision  is  lacking,  but  sight  of  both 
eyes  is  fairly  good  the  treatment  should  begin  by  stereoscopic  exer- 
cise. In  most  instances,  orthoptic  treatment  should  be  preceded 
by  tenotomy.  All  these  treatments,  general  or  orthoptic,  even 
under  the  most  favorable  circumstances,  demand  much  time, 
hence  it  has  been  sought  to  solace  the  victim  of  asthenopia  or  in- 
sufficiency of  convergence  by  means  of  palliatives,  until  the  infirmity 
shall  have  disappeared.  In  short,  it  has  been  sought  to  diminish 
the  convergence  required  for  the  work."      Thus,  he    proposes,  first 


E.  LANDOLT,  M.  D.  69 

to  remove  the  object  to  a  greater  distance  or  necessity  of  holding 
close  by  placing  a  concave  glass,  which  would  stimulate  conver- 
gence, or  put  prisms  on  to  take  the  place  of  convergence. 

The  decentering  of  the  lenses,  that  are  necessary  to  be  worn, 
convex  or  concave,  is  spoken  of.  He  says,  "great  hopes  are  enter- 
tained as  to  the  efficacy  of  prisms  in  the  treatment  of  motor  asthen- 
opia."    These  hopes  have  not  been  entirely  realized. 


The  following  work  is  another  of  the  translations  of 
D.  B.  St.  John  Roosa,  M.  D.,  L.  L.  D.,  Professor  of  Dis- 
eases of  the  Eye  and  Ear,  in  the  New  York  Post  Graduate 
Medical  School,  and  Surgeon  to  the  Manhattan  Eye  and 
Ear  Hospital. 

1889. 

DR.  HERMAN  SCHMIDT-RUMPLER. 

Professor    of    Ophthalmology    and    Director    of   the    Ophthalmologic al 

Clinic,  in  Marburg. 

OPHTHALMOLOGY  AND  OPHTHALMOSCOPE, 
Translated  and  Edited  by 
D.  B.  ST.  JOHN  ROOSA,  M.  D.,  L.  L.  D. 

Asthenopia.— Dr.  Herman  Schmidt-Rumpler,  under  the  head  of 
"Insufficiency  of  the  Internal  Recti,"  defines  Asthenopia  to  be," 
"want  of  endurance  in  close  work."  For  example,  when  the  pa- 
tient reads,  the  letters  become  indistinct  after  a  time  and  are  even 
seen  double.  In  addition,  there  is  pressure  in  and  above  the  eyes; 
headache  and  nausea  may  also  be  observed.  These  symptoms 
depend  upon  the  insufficient  activity  of  the  internal  recti,  which 
soon  grow  tired.  At  first  both  eyes  are  accurately  adjusted  in  read- 
ing; after  a  while  the  power  of  the  interni  relaxes,  and  the  eyes 
assume  a  position  of  divergence.  At  the  same  time  crossed  double 
images  appear,  of  which,  the  patient  usually  is  not  fully  conscious; 
they  produce,  merely,  the  phenomena  of  "swimming"  or  "blurring." 
If  he  again  attempts  to  adjust  properly,  by  a  new  impulse  of  con- 
vergence, the  letters  again  become  indistinct.  The  repeated 
relaxation  and  tension  of  the  muscles  is  a  source  of  the  compli- 
cating nervous   phenomena." 

Under  Asthenopia  Nervosa,  (Retinal  Asthenopia)  complaints  of 
deficient  endurance  in  working,  with  darkening  and  swimming  of  the 
objects  looked  at,  occur  in  cases  in  which,  after  exclusion  of  errors 
of  refraction  and  accommodation,  insufficiency  of  the  interni, 
etc.,    we    can    assume    only   nervous   causes.     In   these  cases,   thcr? 


72  HAZEN'S  NEW  FINDINGS 

arc  usually  pains  in  the  eyes  and  head,  which  continue,  even  after 
the  work  is  abandoned.  There  is  often  great  sensitiveness  to  light. 
The  affection  is  due,  partly  to  general  nervousness,  and  partly  to 
a  local  hypcracsthia  of  the  retina. 

Dr.  Rempler  quotes  Dr.  Noyes,  where  he  states  that,  "insuffi- 
ciency of  the  internal  recti"  may  also  give  rise  to  asthenopia.  He 
eives  the  equilibrium,  "that  is  made  for  a  distance,  which  corres- 
ponds to  the  individual  reading  distance."  Asthenopia,  "weak 
sight,"  is  found  in  hypermetropia.  The  translator  explains,  "that 
the  author,  evidently,  takes  the  view  of  the  relations  of  asthenopia 
to  general  disease,  taken  by  the  vast  majority  of  oculists  throughout 
the  world,  that  is,  that  while  certain  forms  of  headaches,  neuralgias, 
quite  frequently  depend  upon  ocular  defects,  there  is  no  large 
class  of  constitutional  diseases  such  as  chorea,  epilepsy,  or  even 
migraine  in  any  large  proportion,  that  may  be  cured  by  the  use  of 
glasses."  The  balance  or  equilibrium  is  not  discussed,  and  there 
is  no  handling  of  divergent  squint.  (Under  hyperopia.)  "  If 
asthenopic  symptoms  develop,  convex  lenses  must  always  be  re- 
sorted to. 

Treatment. — Should  be  chiefly  directed  to  the  cure  of  the  con- 
stitutional anomalies,  on  account  of  the  obstinacy,  which  is  often 
manifested  by  the  disease  ;  complete  cessation  of  work  and  a  trip 
to  the  country  or  the  mountains  are  sometimes  necessary.  Opera- 
tions on  the  muscles  consist  in  Strabotomy  of  either  the  internal 
or  external  recti.     He  had  no  success  in  the  "stereoscopic  exercises." 


There  has  not  been  a  more  active  or  industrious  man 
in  the  sphere  of  medicine  in  this  country,  or  one  who 
has  done  more  for  the  advancement  of  his  profession 
than  the  late  Dr.  Roosa  of  New  York. 

He  has  written  more  in  his  particular  branches  of  med- 
icine, including  his  translations  of  German  works,  in 
the  specialties  of  Eye  and  Ear",  than  any  other  man  of 
his  time.  He  was  active  in  the  organization  of  Schools, 
Hospitals,  and  Societies — especially  in  Diseases  of  the 
Ear,  he  was  considered  in  the  front  rank  of  his  profession. 

1894. 

D.  B.  ST.  JOHN  ROOSA,  M.  D.,  L.  L.  D. 

Professor  of  Diseases  of  the  Eye  and  Ear  in  the  New  York  Post  Grad- 
uate  Medical   School   and   Hospital;   Surgeon   to   the   Manhattan 
Eye  and  Ear  Hospital;  formerly  Professor  of  Diseases  of  the 
Eye  in  the  University  of  the  City  of  New  York,  and  in  the 
University  of  Vermont. 

A  CLINICAL  MANUAL 

OF 

DISEASES  OF  THE  EYE. 

Asthenopia. — Since  we  have  such  high  authority  for  considering 
a  hypermetropic  formation  of  the  eyeball,  as  being  at  the  founda- 
tion of  most  cases  of  true  asthenopia.  I  fully  adopt  the  opinion, 
including  hyperopia   and  astigmatism. 

Asthenopia  may  be  divided  into  true  or  local,  and  the  false  or 
symptomatic.  I  regard  true  asthenopia  as  that  which  depends 
upon  a  refractive  anomaly,  and  I  consider  that,  as  symptomatic 
or  false,  which  depends  upon  some  error  in  the  general  nutrition, 
neurotic  constitution,  nervous  exhaustion  and  the  like.  These 
have  been  very  much  confounded  in  the  discussions,  which  have 
obtained  in  this  country  on  this  subject.  There  has  been  a  great 
deal  written,  avowedly  not  on  the  basis  of  Donders'  investigations, 


71  HAZEN'S  NEW  FINDINGS 

but  claiming  to  involve  new  ideas  on  this  subject,  which  seems  to 
me,  in  many  instances,  to  he  but  a  going  back  to  the  erroneous 
;  rines,  which  Donders  undertook  to  combat.  Asthenopia 
means  an  inability  to  continue  to  use  the  eyes  on  near  objects, 
without  involving  painful  consequences.  Some  of  those  conse- 
quences are  at  once  appreciable,  and  cause  the  patient  to  stop 
his  occupation,  indeed,  compel  him  to  do  so."  Here  he  adds  to 
the  list  of  other  writers,  "inflammation  of  the  edge  of  the  lids, 
peculiar  headaches."  Certain  constitutional  conditions  that 
involve  accommodative  fatigue  of  the  ciliary  muscles,  may  pro- 
duce symptoms  simulating  true  asthenopia,  but  these  should  be 
carefully  distinguished  from  those  resulting  from  errors  of  refraction. 
Epilepsy,  chorea,  etc.,  have  been  thought  to  result  from  these 
conditions.  With  that  doctrine,  I  have  no  sympathy.  Latent 
errors  of  refraction  have  very  little  to  do,  as  a  rule,  in  my  opinion, 
even  in  the  causation  of  asthenopia,  and  nothing  whatever  in  the 
production  of  constitutional  disease. 

Muscular  Asthenofia. — Although  I  formerly  accepted  the 
ordinary  classification  of  an  asthenopia,  dependent  upon  insuffi- 
ciences  of  the  external  ocular  muscles,  I  have  finally  come  to  reject 
it  altogether.  Of  course,  I  do  not  deny  the  existence  of  insufficien- 
ces  of  the  interni,  chiefly  in  myopia,  and  the  externi,  principally  in 
hypermetropia,  nor  do  I  deny  that  there  are  many  eyes,  whose  exter- 
nal muscles  are  not  capable  of  doing  the  average  degree  of  work, 
but  I  hold  that  all  these  conditions  depend  on  static  fixed  condi- 
tions of  the  eyeball;  that  they  are  direct  consequences  of  these 
conditions  and  should  not  be  denied  a  special  nomenclature,  but 
should  be  classed  under  the  head  of  asthenopia  occurring  in  Myopia, 
Hypermetropia,  Hypermetropic  Astigmatism,  etc.,  from  faulty 
conformation  of  the  eye.  I  formerly  measured  the  relative  power 
of  muscles;  this  relative  power  varies  in  different  individuals, 
who  have  no  trouble  with  their  eyes,  and  I,  therefore,  no  longer 
measure  it.  Physiologically,  it  may  be  interesting,  but  it  can  do 
nothing  toward  the  proper  treatment.  Then  Myopia,  being 
rarely  asthenopic.  its  congestion  or  inflammation,  which  is  thought 
to  be  asthenopia,  is  not  true  asthenopia;  neurotic  invalids,  suffering 
from  neurasthenia,  often  have  great  difficulty  in  using  their  eyes, 
but  they  also  have  difficulty  in  performing  many  other  functions 
of  the  body.  No  adaptation  of  glasses  will  materially  assist  such 
persons,  except  by  what  may  be  termed  suggestion. 

Roosa  says,  "that  Donders  mentioning  muscular  asthenopia  in 
his  book  was  "owing  to  his  reverence  for  the  opinions  of  Graefe," 


D.  B.   ST.  JOHN  ROOSA,   M.  D.  75 

and  further  on  he  says,  "I  believe  that  if  we  set  aside  sentiment  as 
to  Graefe's  discoveries  and  preconceptions,  and  examine  asthenopia 
in  the  light  of  Donders'  work  upon  hypermetropia  and  that  of 
Javal  upon  astigmatism,  we  shall  have  no  occasion  to  look  to  in- 
sufficiences  as  faults  needing  correction,  except  when  they  cause 
deformity  or  destroy  binocular  vision,  when,  if  possible,  they  are 
to  be  removed  by  operations.  The  sources  of  true  asthenopia 
and   its  results    are,  in   my    judgment,  to  be  found   in   Ametropia. 

Treatment. — His  treatment  is  by  attention  to  ametropia  only. 
He  remarks  that,  in  his  opinion,  the  very  best  that  can  be  done  for 
them  is  to  make  rather  light  of  their  troubles,  and  correct  their 
astigmatism.  This  accomplishes  more  than  any  other  system  of 
treatment,  and  If  the  practitioner  is  firm  with  them  and  informs 
them  that  this  is  the  best  that  can  be  done,  they  go  on  with  their 
work  and  do  it  with  very  little  inconvenience.  The  examinations 
are  not  extended  to  the  inquiry  of  balance  or  equilibrium,  but  the 
thought  is  that  the  equilibrium  or  imbalance  has  no  significance. 
He  has  abandoned  tenotomy  and  use  of  prisms  for  the  correction 
of  muscular  anomalies,  and  believes,  "that  the  nomenclature  to 
describe  weakness  of  the  muscles  should  disappear."  He  has  found 
astigmatism  to  be  the  cause  and  its  correction  the  cure.  "The 
Asthenopia  with  us  in  the  U.  S.  is  directly  traceable  to  the  weakened 
constitutional  conditions." 


The  voluminous  and  Encyclopedic  method  of  compiling 
"System  of  Diseases  of  the  Eye,"  and  its  extensive  in- 
troduction into  the  libraries  of  the  Oculists  of  this  country, 
gives  weight  and  authority  to  any  part  of  the  subject 
of  Ophthalmology.  As  this  division  of  the  work  is 
handled  by  one  of  the  editors  of  this  system,  it  draws  a 
closer  attention  to  the  views  taken  by  its  writer  than 
if  apportioned  to  another.  We  therefore  give  it  much 
space. 

1900. 

CHARLES  A.  OLIVER,  A.  M.,  M.  D. 

Attending  Surgeon  to  the   Wills'   Eye   Hospital;  Ophthalmic  Surgeon 
to     the     Philadelphia     Hospital,     Philadelphia,     Penn. 

AMETROPIA:     ITS  ETIOLOGY,  COURSE  AND  TREATMENT 
SYSTEM   OF  DISEASES   OF  THE  EYE.     VOL.  IV. 

That  the  eye  of  the  savage  differed  from  that  of  the  civilized 
man  is  made  manifest,  when  the  modes  of  livelihood  are  con- 
trasted. 

The  savage  gazed  for  brief  periods  of  time,  at  near  things,  and 
educated  his  visual  power  for  distant  objects  both  day  and  night. 

The  civilized  man  engaged  in  in-door  pursuits;  his  visual  organs 
had  to  be  adapted  to  near  work. 

The  wear  and  tear,  in  this  latter  type,  is  greater  and  is  so  often 
abused  that  there  is  structural  impairment. 

These  are  the  physical  penalties  of  increased  mental  force,  and  the 
consequence  is,  that  man  must  accept  the  conditions,  so  that  he 
may  enjoy  the  fruits  of  civilization  and  culture. 

The  overtaxed  visual  function  is  manifest  among  the  professions, 
the  artizans,  seamstresses,  weavers,  and  even  the  house-wife.  The 
newborn  may  be  given  an  inheritance  unstable,  and  not  able  to 
withstand  any  ordinary  amount  of  use.  It  signifies  a  transmitted 
fault,  expressing  itself  through  physical  or  physiological  impair- 
ment. 


7^  HAZENS   NEW   FINDINGS 

i  laminations  show,  that  the  ordinary  shape  of  the  unemployed 
eye  of  the  human  species,  presents  a  short  diameter  to  the  entering 
rays  of  light.  Similar  peculiarities  of  structure  exist  in  the  eye, 
such   as  differences   in  cephalic  configuration  and  facial  contour. 

The  "normal  eye"  is  not  one  with  the  findings  mathematically 
correct  or  that  of  the  emmetropic  standard,  but  that  in  which  the 
perfect  visual  result  is  obtained.  It  is  doubtful  whether  the  ideal 
one  exists.  The  emmetropic  eye  is  the  transitional  stage  between 
hypermetropia  and  myopia.  It  is  one  which  focuses  distant  par- 
allel rays  on  its  foveal  plane  without  muscular  effort,  giving  dis- 
tinct images  of  distant  objects.  "It  is  a  refractive  halt  in  an 
asthenopic  eye."  Practically,  it  should  always  be  sought  for. 
"The  condition  artifically  obtained,  is  however,  not  always  the  best 
for  the  well  being  of  the  organ." 

"There  are  two  end  organs,  each  of  which  receives  a  sensory 
impression,  which  it  is  necessary  to  combine  into  a  single  perception- 
binocular  single  vision." 

"Though  ametropia  is  as  wide  spread  as  the  world  itself,  yet 
asthenopia  is  the  bane  of  the  civilized  minority."  It  is  dependent 
on  many  interrelated  and  interdependent  conditions,"  for  example, 
ametropia  and  asthenopia  make  their  appearance  or  heterophoric 
asthenopia  is  provoked.  The  first  is  that  which  includes  in  its 
etiology  both  the  sensory  and  motor  disturbances,  that  have  their 
origin  in  badly  shaped  eyeballs.  The  second  has  for  its  cause 
ideopathic  or  functional  errors  in  muscle  eqilibrium,  that  may 
be  independent  of  the  shape  of  the  eyeball  and  the  condition  of 
the  refraction." 

"Heterophoric  Asthenopia  is  not  so  rare  as  may  be  supposed, 
be  the  ametropia  ever  so  slight  or  undisturbing,  or  even  if  emmetro- 
pia  be  found,  asthenopic  symptoms  of  heterophoric  type  may  be 
present.  Moreover,  ideopathic  or  primary  heterophoria,  par- 
ticularly hyperphoria,  may  not  only  produce  a  heterophoric  asthen- 
opia, but  may  also  provoke  an  ametropic  one  from  a  latent  ame- 
tropia, which  would  not  have  been  brought  into  evidence  had  there 
not  been  a  normal  equilibrium  and  action  of  the  ocular  muscles" 

Asthenopia. — "Considered  broadly,  Asthenopia  or  eye-strain 
is  a  complex  grouping;  as  a  rule,  it  is  expressive  of  the  combined 
workings  of  the  two  ocular  end  bulbs  and  their  accessories." 
"What  may  be  considered  the  normal  state  of  the  visual  apparatus 
today  need  not  be  that  of  tomorrow.  "Normality  can  be  assumed, 
no  matter  what  inequality  may  exist,  as  long  as  the  two  series 
of  ocular  muscular  groupings  are  in  balance  and  continue  so  during 
activity." 


CHARLES  A.  OLIVER,  M.  D.  79 

"It  is  the  heterophoric  type  of  asthenopia,  particularly  the 
hyperphoric  variety  of  minor  degree,  more  than  it  is  the  ametropic 
one,  which  gives  rise  to  so  many  reflex  neuroses.  It  is  this  type 
of  disorder  that  dizziness,  gastric  disturbances,  with,  for  example, 
urticaria,  vertigo,  migraine,  nervous  irritability,  mental  confusion, 
insomnia,  etc.,  all  of  which  are  so  prone  to  interfere  with  general 
nutrition,  come  into  existence." 

"In  this  category  are  to  be  found  the  many  changes  of  vaso- 
motor type.  In  this  group  are  to  be  seen  the  characteristics  of 
the  vicious  circle  of  cause  and  effect;  eye  strain,  with  its  pain  and 
nervous  disturbances,  producing  interference  with  assimilation  and 
nutrition,  which,  in  its  turn,  so  reduces  the  general  physical  condi- 
tion as  to  induce  an  increase  of  the  asthenopia." 

Nerve  Storms. — "The  nerve  storms  that  are  produced  by  heter- 
ophoria  (as  also  ametropia)  may  produce  a  rapid  discontinuance  of 
near  work,  so  that  the  more  distant  reflexes  may  never  be  given  an 
opportunity  to  manifest  themselves.  There  may  be  so  strong 
nerve  tone  that  the  excitation  may  never  make  an  impression — 
just  as  ametropic  and  heterophoric  asthenopia  may  produce  far 
reaching  and  injurious  symptoms  that  cannot  be  removed  in  any 
other  way  than  by  correction  of  the  local  defects" — so  must  general 
disturbances  be  remediable  by  therapy,  "directed  to  the  casual 
factors." 

In  the  neurotic,  toxaemic  and  anaemic,  small  errors  sooner  mani- 
fest their  presence.  Some  of  the  functional  nervous  diseases  and 
some  of  the  morbid  processes,  named  neurasthenia,  chorea,  epilepsy 
"may   be   indirectly   dependent   upon   disturbed    binocular  action." 

Neurasthenia. — Neurasthenia  produces  Asthenopia;  Functional 
Paresis  of  the  motor  apparatus;  irregularity  of  pupils;  lachryma. 
tion;  congestion;  sensation  of  foreign  material  in  the  conjunctival 
sac  from  want  of  tone  and  localized  dilation  of  the  vascular 
walls,  with  a  sense  of  weight  and  a  tendency  to  drooping  of  the 
upper    eyelids,    hyperesthesias,    and   irregular  spasmodic  actions. 

Heterophoria. — "It  is  the  minor  and  unequal  degrees  of  hetero- 
phoria  (particularly  hyperphoria)  that  produce  the  most  disturbing 
reflex  symptoms.  This  is  especially  so,  if  there  be  some  peculi- 
arity of  angle  of  muscle-deviation  or  fault}'   muscular  tendency." 

"Neuralgia,  the  functional  expression  of  a  disturbed  nerve,  is 
one  of  the  most  common  signs  of  ametropia." 

"In  the  trifacial  and  second  cervical  groupings,  on  use  of  eyes, 
it  manifests  itself,  especially  when  the  system  is  below  par.     Low 


SO  HAZEN'S   NEW  FINDINGS 

grade  of  compound  hypermetropic  astigmatism,  mixed  astigmatism, 
etc.,  produce  the  greatest  amount  of  headache;  anisometropia, 
and    antimetropia,    increase   the   frequency   of   cephalalgia. 

Differential  Diagnosis. — "As  yet,  the  differential  diagnosis 
between  the  cephalalgia  of  ametropia,  and  that  of  heterophoria  is 
uncertain,  though  it  is  probable  that  when  the  pains  are  associated 
with  dizziness,  and  car  "sickness,"  that  abnormal  balance  is  the 
more  to  blame.  As  a  rule,  however,  the  two  conditions  are  asso- 
ciated and  interdependent." 

Local  Reflex  Eye  Strain. — Asthenopia  may  be  produced  by 
conjunctival  and  pulpebral  irritation  and  inflammation,  associated 
with  pterygia,  chalazia  and  abnormal  adhesions  of  lids.  Whether 
naso-pharyngial  disturbances  can  be  included  in  this  category  is 
uncertain,  although  the  removal  of  adenoids  has  directly  relieved 
cases  in  which  the  correction  of  the  ametropia  and  the  heterophoria 
has  availed  little  or  nothing.  Nasal  reflexes  and  dental  caries 
must  also  be  considered.  Many  subjects,  suffering  from  frontal  neu- 
ralgia and  complaining  of  eyestrain  on  rising  in  the  morning,  may 
be  dependent  upon  congestion  of  nasal  cavities,  conjunctival 
irritation,  that  has  been  provoked  the  evening  before  by  improper 
use  of  the  eyes. 

Spastic. — "In  the  spastic  or  overacting  types  of  heterophoric 
asthenopia,  particularly,  when  there  is  hyperhoria  and  the  interior 
muscles  are  also  affected,  migrainous  attacks  are  common."  "In 
the  forced  or  over  acting  exophoria,  the  more  general  signs  ,such  as 
vertigo,  incoordination,  mental  peculiarities,  and  even  insomnia, 
and  neurasthenia  are  noticeable." 

"Undue  action  of  the  interior  muscles  (sphincter  irides  and  the 
ciliary)  being  supplied  by  the  third  nerve  affects  all  the  related 
exterior  muscles  and  produces  a  departure  of  the  globe  from  ortho- 
phoric  equilibrium." 

Paretic — The  paretic  or  underacting  form  of  heterophoric 
asthenopia,  found  so  frequently  in  the  aesthenic  is  dependent  on 
weakness  of  the  muscles  of  the  third  nerve.  The  symptoms  vary 
in  all  forms  of  cephalalgia  from  mere  frontal  to  fronto-occipital 
pain;  the  greatest  disturbance  always  being  found  in  the  positions 
of  the  weakest  groupings  or  combinations  of  muscles.  In  a  mixed 
type  (underacting  and  paretic)  where  the  extrinsic  and  intrinsic 
muscles  are  weak  from  general  debility,  there  is  a  subnormal  ciliary 
action,  associated  with  dilated  pupils  and  exophoria,  during  near 
vision  in  which  there  is  both   ametropia   and   heterophoric  disturb- 


CHARLES  A.  OLIVER,  M.  D.  81 

ance,  with  an  inability  for  prolonged  focusing,  imperfect  fixation, 
visual  confusion,  dizziness,  and  gastric  disorders.  Xot  only  the 
muscles  supplied  by  the  oculo-motor,  but  those  of  the  fourth 
and   sixth   become  lowered   in  action. 

Climate. — Climate  as  an  etiological  factor,  as  a  cause  of  astheno- 
pia, is  discussed,  in  that,  in  one  section,  there  is  more  strenuousnes 
required  to  obtain  the  necessities  of  life  than  in  the  other,  where 
nature  supplies  the  fruits  to  appease  the  appetites  with  less  labor. 

Life  Struggle. — Then,  added  to  the  struggle  of  life  for  sub- 
sistence, the  procuring  of  the  necessities,  and  those  living  in  the 
more  rugged  climates,  set  standards  of  skill,  education  and  profi- 
ciency, all  of  which  "cause  wear  and  tear  of  the  structural  organs," 
and  in  the  case  of  the  eye""  are,  unremittingly,  and  often  injur- 
iously brought  into  play" — hence  it  is  not  possible  to  consider  the 
functions  of  the  visual  organs  as  dominated  by  any  mathematical 
laws,  but  the  adoption  of  anatomic  elements  subserve  the  purpose 
for  which  they  were  intended. 

Muscle  E(  uilibrium. — Among  the  etiological  causes  of  hetero- 
phoric  disturbances,  the  great  majority  of  faulty  muscle  equilibrium 
is  the  result  of  a  transmitted  over  stimulation,  given  to  the  ciliary 
muscle,  the  consequence  of  ametropia;  it  is  an  associated  error, 
the  effect  of  individual  imperfection.  "In  the  vast  majority  of 
cases,  muscle  disturbance  is  the  result  of  unlike  degrees  of  minor 
amounts  of  ametropia  in  two  organs  that  are  found  to  work  as 
one  organ."  Comfortable  vision  may  be  with  heterophoria,  both 
manifest  and  latent.  It  may  be  the  result  of  a  spastic  condition 
of  one  muscle  and  a  paretic  condition  of  another. 

Astigmatism. — As  one  of  the  causes  of  astigmatism  is  the  tonic 
contraction  of  the  exterior  ocular  muscle  groupings,  a  spastic 
condition  of  a  series  of  extra  ocular  muscles,  as  is  occasionally  seen 
in  some  types  of  nerve  disease.  Both  surfaces  of  the  cornea  and 
of  the  lens,  as  well  as  the  density  of  the  different  portions  of  the 
two  masses,  must  be  taken  into  consideration. 

The  astigmatism,  determined  in  examination  of  each  eye  separa- 
tely, is  often  different  in  amount;  when  the  examination  is  made 
with  the  eyes  simultaneously,  the  angles  of  the  meridians  likewise 
change.  This  is  possibly  accounted  for  by  the  extra  ocular  muscles, 
producing  different  degrees  of  tension  in  their  combined  functioning. 

Heterophoria. — Muscle  equilibrium  is  pronounced  in  cases  of 
one  or  even   two  degrees  of  deviation,    (exophoria   in   myopes   and 


82  HAZEN'S  NEW  FINDINGS 

horia    in    hypcrtropcs)    for  five  or  six  meters  distant  and  slight 
exophoria    at    reading   distance.     Jt    is   seen   in   cases   in   which    the 
gmatic  axes  arc  at   'JO  degrees.     The  deviation   in   the  vertical 
direction  is  much  inure  troublesome. 

"Heterophorias  soon  become  apparent  with  the  minor  degree 
of  ametropia,  particularly  of  the  astigmatic  variety.  Latent 
ezophorias  are  often  made  manifest  by  the  use  of  prisms  and  the 
repeated    performance   of   the    so   called    graduated    tenotomies." 

•'IIvperaesophorias  are  quite  common  in  young,  highly  hyper- 
metropic and  astigmatic  subjects,  while  hyperexophorias,  with 
slightly  dilated  pupils,  are  the  rule  in  the  middle  and  the  high 
grade  myopes.  The  extra  ocular  muscle  imbalances  are  the  greatest 
in  antimetropic  and  anisometropic  subjects." 

Like  ametropia,  heterophoria  is  divisible  into  manifest,  latent 
and  total. 

The  local  symptoms  of  external  deviations  are  frequently  those 
that  have  been  shown  to  be  dependent  on  underaction  and  paresis. 

"'An  odd  symptom  is  the  sensation  of  a  sudden  impact  against 
the  eye  ball,  produced,  probably,  by  a  simultaneous  action  of  two 
or  more  of  the  recti  muscles;"  ptosis  may  be  caused  by  hyperme- 
tropic disturbances,  tilting  of  the  head  away  from  the  shoulder 
corresponding  with  the  hyperphoric  eye;  palpebral  hyperemia 
with  watering  of  the  eye;  diminished  vision,  and  comprising  double 
vision  as  seen  in  car  sickness,  with  all  manner  of  general  reflexes 
that  are  more  or  less  distantly  related,  constitute  some  of  the  other 
signs  of  heterophoria. 

Cyclophoria  is  an  imbalance  of  equilibrium  and  action  of  the 
exterior  ocular  muscles.  It  is  most  frequently  seen  in  oblique 
astigmatism  and  is  mainly  connected  with  the  oblique  muscles. 

Facial  wrinkles,  corrugations  and  even  grimaces  are  sympto- 
matic of  heterophoria. 

A  variety  of  general  symptoms  are  not  noted  until  the  ametro- 
pia or  heterophoria  are  corrected,  thereby  getting  rid  of  an  expendi- 
ture of  nervous  energy,  which  would  have,  if  continued,  been  an 
injurious  influence  upon  the  general  health. 

It  must  not  be  forgotten  that  general  organic  lesions,  particu- 
larly  those   of   neural   structures,    may    give    rise   to   similar   signs. 

Prognosis. — With  proper  care  and  rest,  work  can  be  secured 
from  the  visual  organs.  "Mischief  manifests  itself  when  friction 
begins,    and    if    not    recognized    and    corrected,    is    apt    to    produce 


CHARLES  A.  OLIVER,  M.  D.  83 

physical  disorders."  Ametropia  has  no  major  place  in  the  statistics 
of  blindness,  but  it  slowly  extends  its  harmful  impulses,  which 
frequently  are  but  imperfectly  recognized,  and  so  imperfectly 
corrected  that  its  evil  consequences  become  more  widely  spread." 
In  the  sedentary  lives  of  asthenopes,  "the  weakened  sight  is  but 
one  of  the  evidences  of  general  nerve  tire." 

In  a  country  where  myopia  was  increasing,  attention  was  called 
to  asthenopia  two  decades  ago,  and  America  profited  by  the  object 
lesson,  and  reform  has  been  the  result,  through  her  optical  estab- 
lishments as  in  other  hygienic  measures.  Notwithstanding  the 
"want  of  harmonious  binocular  action,"  until  the  last  decade  and 
a   half,  it  has  generally  remained  untreated. 

Owing  to  the  general  strenuousness  of  our  people,  where  so  much 
nerve  energy  is  wasted,  we  find  asthenopia  at  its  worst. 

"Such  a  complex  organ,  so  situated,  as  its  work  continues,  must 
cause  harmful  influences  on  distant  related  organs." 

The  private  schools,  whose  pupils  are  from  the  well  to  do  classes, 
with  less  rugged  constitutions,  afford  illustrations  of  the  causes  and 
effects  of  asthenopia;  physical  unfitness,  and  inadequate  strength 
for  the  performance  of  their  real  life  work,  especially  among  brain 
workers  are  some  of  the  results;  neurasthenia  becomes  manifest 
and  the  eyes  are  among  the  earliest  organs  to  become  involved. 
The  effects  of  impaired  vision  on  the  intellectual  development 
and  physical  growth  of  the  subject  are  marvelous,  often  unrecog- 
nized until  too  late,  when  the  disturbance  becomes  increasingly 
harmful. 

Theoretically,  the  emmetropic  have  the  fewest  injurious  influences; 
practically,  there  cannot  be  any  ocular  ideal,  and  an  emmetropic 
eve  cannot  be  expected  to  remain  so,  when  its  dioptric  media  is 
so  changeable,  and  its  muscular  movements  so  indeterminate. 
Lens  Therapy  should  be  subject  to  legal  regulation. 
Municipal  statutes  should  be  enacted  for  the  examination  of 
pupils. 

Correction  of  ametropia,  particularly  astigmatism,  has  lessoned 
myopia;  disastrous  intraocular  changes,  associated  with  myopia, 
are  not  so  frequently  seen  at  the  present. 

Myopia  is  a  direct  accompaniment  of  advanced  civilization,  but 
cannot  be  attributed  to  embryologic  causes.  Mental  pursuits 
require  prolonged  near  vision  from  early  life,  and  therefore  the  best 
sight  attainable.  Uncomplicated  Myopia  is  rare  and  the  lower 
grades  of  the  schools  present  but  little  asthenopia. 

Minor  degrees  of  ametropia  and  heterophoria  produce  impair 
ment   of   nerve   energy,    by   abnormal   expenditure   of   nerve    force; 


84  HAZEN'S   NEW    FINDINGS 

early   correction    leaves    fewer   chances   of   nervous    impairment   or 
organic  disturbance'. 

Treatment,  —"A  normal  eye  is  one  that  has  healthy  tissues  and 
is  functioning  properly."  '"It  need  not  be  emmetropic  nor  neither 
need  it  be  exactly  like  its  fellow.  By  over  use,  however,  pain  is 
produced  and  rest,  orthopedy  by  lenses  and  prisms  must  be  applied. 
\\  hile  improvement  in  vision  is  brought  about,  ocular  disease  is 
the  main  condition  to  be  improved.  The  uncomfortable  vision 
before  inflammation  and  acuteocular  pain  are  theprincipalsymptoms 
that  send  the  ametrope  for  relief,"  and  the  almost  universal  belief 
that  all  defective  vision  can  be  relieved  by  lenses  acts  disastrously 
on  the  welfare  of  the  organ." 

The  science  of  prescribing  for  ametropia  is  not  a  mechanical 
art.  It  is  the  work  of  the  educated,  who  understand  the  signifi- 
cance of  the  eye  strain  on  the  general  health.  The  end  organ  is 
improperly  compared  to  a  camera — it  is  a  living  mechanism.  The 
employment  of  a  correcting  lens  is  medical  therapy.  Like  other 
therapeutic  aid,  its  virtues  have  been  exaggerated. 

Eighty  per  cent  of  Opthalmic  work  is  for  the  correction  of  ame- 
tropia. Unlike  our  ancestors,  people  of  the  present  day  need  not  be 
doomed  to  pursue  lives  of  uselessness,  out  of  doors;  on  the  contrary, 
scientific  medicine  would  be  criminal!}'  negligent  to  give  such  advice, 

\\  e  cannot  expect  to  cure  "static"  ametropia  without  surgical 
procedure,  but  "dynamic"  can  be  cured,  both  by  local  and  general 
methods.  The  orthopedic  therapy  is  a  lens  and  acts  as  a  crutch, 
and   it   cannot   be   expected   to   remain   efficient  without   changing. 

Lenses  should  not  be  used,  merely  to  benefit  vision,  but  to  pre- 
vent disturbing  causes  and  disordered  mechanism.  It  is  not  the 
amount  of  ametropia,  which  determines  their  necessity.  A  cylin- 
drical lens  of  12.  D.  has  frequently  done  more  good  as  a  thera- 
peutic measure,  in  changing  muscle  imbalance  than  general  treat- 
ment, or  so  called  "rest  lenses." 

"All  refractive  errors,  especially  minor  degrees  of  astigmatism, 
should  be  carefully  estimated  for,  at  least  as  low  strength  as  one 
eighth  of  a  diopter." 

The  total  error,  particularly  the  astigmatic  one,  must  be  found, 
before  the  proper  orthopedic  help  to  the  combined  organs  can  be 
established.  In  all  subjects  under  45  years  there  must  be  full 
paralysis    of   ciliary    muscles. 

Select  a  cycloplegic  that  is  deemed  best  adapted  to  the  particular 
case  and  get  full  effect  of  control  of  accommodation. 


CHARLES  A.  OLIVER,  M.  D.  85 

"To  relieve  asthenopia,  it  is  just  as  important  to  obtain  definite 
data  of  heterophoric  changes;"  artificial  control  of  the  extra  ocular 
muscles;  we  do  not  have  to  determine  the  amount  of  heterophoric 
action,  particularly  the  latent  in  any  definite  position,"  though 
clinically,  the  muscle  equilibrium,  for  distance,  may  often  be  ad- 
vantageously tried,  while  the  ciliary  muscle  is  artificially  paralyzed." 

Prismatic  corrections  have  their  limitations.  "During  their  use, 
there  should  be  definite  modifications  of  power  for  every  finite 
point  used.  Unfortunately,  in  such  corrections,  there  are  the  most 
troublesome  factors  of  identical  points,  that  are  situated  throughout 
the  associated  fields  of  vision." 

No  therapy  of  any  kind  should  be  applied  to  the  extra  ocular 
muscle  until  the  ametropia  is  relatively  corrected;  the  powers  of 
the  combined  muscle  action,  in  the  four  principal  directions,  must 
be  learned  and  the  inter-relationship  of  the  two  ciliary  muscles 
must  be  studied.  "It  is  a  series  of  motor  impulses  in  unstable 
muscular  apparatus  of  dual  type,  independent  of  set  mathemat- 
ical rules  and  fixed  certainties." 

Optometry,  the  science  of  measuring  the  optical  powers  of  the 
eye,  in  practice,  divides  itself  into  objective  and  subjective;  1st. 
Opthalmoscopy-Keratometry  and  the  Fundus  Reflex  test  are  em- 
ployed. 2nd.  Test  Lenses.  For  determining  related  muscle 
imbalance,  both  objective  and  subjective  tests  should  be  applied 
both  for  distance  and  working  point,  and  also  for  other  focusing. 

"The  methods  of  testing  heterophoria,  are  as  a  rule,  very  im- 
perfect." The  muscular  condition  should  be  gotten  repeatedly, 
in  order  to  gain  averages  of  muscle  balance.  "The  duction  powers 
of  muscle  combinations  that  produce  the  various  combined  ocular 
movements,  must  always  be  tested." 

Prescribing  lenses  brings  into  consideration  a  whole  series  of 
dynamic  forces,  situated  in  and  around  two  closely  related  eyeballs. 
It  is  one  of  the  most  difficult  problems,  given  a  physician,  and  is 
one  of  the  most  important  therapeutic  agents  that  has  been  offered 
to  the  profession. 

Xo  case  of  binocular  ametropia  has  been  properly  treated  until 
the  disturbances  of  both  the  related  extra  ocular  and  intra  ocular 
muscle  groupings  (which  are  brought  into  almost  momentary 
play)  are  gotten  rid  of  as  nearly  as  possible. 

"The  production  of  an  artificial  ametropia  is  not  infrequently- 
necessary,  in  order  to  obtain  a  pair  of  comfortably  working  and 
non-irritating  visual  organs." 

The  secret  is  to  bring  about  as  close  a  proper  relation  between 
the   two   conditions   (extra   and   intra   ocular   premises)    in   each   in- 


86  HAZEN'S  NEW  FINDINGS 

dividual  case  as  possible,  hoping  only  to  approach  the  ideal  state. 
"'As  a  rule,  a  total  correction  of  binocular  ametropia  (particularly 
the  minor  types)  not  only  removes  a  false  tendency  of  the  globes, 
in  some  definite  direct  ion,"  but  "restores  the  extra  ocular  and  the 
intra-ocular  series  of  muscles  to  a  normal  inter-relational  balance, 
thus  permitting  proper  equipoise,  without  undue  or  harmful  in- 
nervation impulses  to  take  place,  when  moved  into  associated 
positions. 

"In  the  majority  of  cases,  the  question  is  to  get  the  two  eyes  to 
work  together  harmoniously  ,for  the  generally  employed,  distant 
or  near  working  points;  to  reduce  the  optical  and  the  muscular 
strains  to  a  minimum,  in  agreement  with  what  it  is  expected  of 
the  organs  to  perform."  "Normality  and  emmetropia  need  not 
be  the  same;  it  may  not  be  the  best  practical  basis." 

In  heterophoria,  when  amblyopia  is  threatened,  correction  of 
ametropia,  stereoscopic  exercises,  periodic  use  of  the  organs  should 
be  carefully  attended  to.  If  vision  remains  below  normal,  radical 
procedures  may  be  resorted  to.  Each  form  of  therapy  has  its 
limitations   and    operation   as   an   ultimatum. 

"Orthopedic  treatment  of  ametropia  should  really  be  frequently 
considered  as  to  removal  of  the  etiological  factors  in  asthenopic 
symptoms."  "Prisms  combined  with  sphericals  instead  of  cylin- 
ders signify  uncorrected  muscle  balance,  which  might  be  remedied 
by  sphero-cylinder." 

Ideopathic,  that  is  anatomic,  is  the  only  type  of  heterophoria  that 
legitimately  permits  operation,  and  this  is  the  only  remedy.  "It 
must  be  "structural"  or  "insertional"  in  character." 

"For  removal  of  reflex  disturbances,  reflex  irritants  or  the  offending 
relationship  must  be  sought." 

In  functional  forms,  after  correction  of  ametropia,  there  should 
be  hygienic  attention  to  general  nerve  tone.  "Rythmic  exercises, 
not  carried  to  excess,  and  in  some  instances  innervation  impulse 
tests  are  of  use. 

"These  two  types  of  heterophoria  are  distinctly  separated," 
and  the  two  procedures  can  be  accomplished  only  by  the  scientific 
medical  man. 

"If  the  external  groupings  are  suffering  from  the  secondary 
exhaustion,  much  good  can  be  done  by  obtaining  and  retaining  a 
normal  working  balance  between  the  two  related  series."  Never 
in  heterophoric  or  heterotropic  errors  should  attempts  be  made 
to  weaken  any  set  or  sets  of  muscles.  Find  the  weak  and  strengthen 
them   by   orthopedic   measures. 


CHARLES  A.  OLIVER,  M.  D.  87 

The  paretic  type  is  evidently  dependent  on  general  systematic 
disturbance.  Hygiene  and  internal  medicine  are  indicated.  Forms 
of  strychnia,  hypodermatically  administered.  Local  therapy  is 
useless  without  general  treatment. 

In  the  neurasthenic  types,  frequently  seen  among  the  intellectual, 
optical    and    musculo-dynamic    correction    are   of    but    little    value. 

Prolonged  and  absolute  change,  rest  and  properly  taken  exercise, 
both   physical  and   mental,  can  alone  effect  a  cure. 

A  partial  correction  of  astigmatism,  or  even  omission  of  the 
astigmatism  found  in  cycloplegia,  and  in  others,  a  frequent  change 
of  axes  may  be  of  value. 

For  slight  esophoria,  for  distance,  prisms  are  not  best.  In  low 
degrees  of  exophoria  for  near  vision,  base  in,  prisms  can  be  put 
before  the  helping  eye.  If  later,  muscle  equilibrium  be  again  dis- 
turbed, as  it  frequently  is,  "hygiene  of  eye  employment,  temporary 
cessation  of  work,  spherical  and  prismatic  correction  and  genera) 
constitutional  remedies  are  employed. 

Theoretically,  "the  cure  of  asthenopia  is  the  artificial  production 
of  emmetropia  and  orthophoria,  yet  practically,  such  ideals  are 
rarely  preserved,"  "nothing  more  can  be  expected  in  the  removal 
of  asthenopic  conditions  than  to  approach  as  near  to  a  refraction 
and  muscular  ideal  as  possible." 

Some  cases  of  "spasm  of  accommodation"  are  so  persistant  as  to 
require  months  of  active  treatment. 

"Migraine  is  one  of  the  main  causes  of  ocular  disturbance." 
Clinically,  get  the  eyes  into  a  normal  state,  and  hygienically  treat 
generally  associated  neurotic  conditions,  which  are  probably  one 
of  the  principal  casual  factors  in  the  production  of  the  affliction." 

Habit  Chorea  of  refractive  origin,  has  a  tendency  to  invade  other 
muscular  groupings  besides  those  of  the  eye-lids  and  face,  and  is 
bettered  by  correction  of  ametropia  and  heterophoria. 

Headache.  It  would  be  well  to  estimate  the  refraction  in  all 
cases  of  functional  neurosis,  situated  around  the  eyes. 

Presbyopia.  The  ametropia  of  each  eye  must  be  considered. 
This  done,  the  artificial  combined  points  for  near  work  can  readily 
be  obtained.     Properly  centering  should   have  the  same  care. 

"In  the  placing  of  prisms  in  lenticular  corrections,  it  is  best  to 
put  the  bulk  of  the  prismatrc  action  before  the  helping  eye,  which 
is  generally  the  left  one." 


The  contribution  to  the  science  of  Ophthalmology  by 
Dr.  Stevens,  in  instruments  of  precision  in  Diagnosis 
and  his  new  nomenclature  in  Muscular  Anomalies,  and 
the  new  views  in  which  he  presented  the  relation  of  the 
extra-ocular  muscles  to  the  subject  of  Functional  \  ision, 
together  with  his  method  of  relief  of  asthenopia  by  "grad- 
ual tenotomy"  marks  an  epoch  in  the  history  of  Oph- 
thalmology. 

1906. 

GEORGE  T.  STEVENS,  M.  D.,  Ph.  D. 

A  TREATISE  ON  THE  MOTOR  APPARATUS  OF  THE  EYES. 

MOTOR  APPARATUS  OF  THE  EYE. 

This  work  follows  his  book  of  "Functional  Nervous  Diseases,"' 
published  in  1884.  The  central  doctrine  in  this,  he  states  in  the 
preface,  is  difficulty  of  adjustment  of  eyes,  which  is  a  source  of  ner- 
vous trouble,  and  more  frequently  than  other  conditions,  consti- 
tutes  a    neuropathic   tendency. 

He  gives  an  interesting  history  of  how  the  ancients  regarded 
deviation  of  the  eyes,  and  states  that  the  opinions  expressed  as  to 
cause,  were  copied  by  subsequent  writers  and  thus  handed  down 
nearly  to  our  own  day. 

In  the  history  of  muscular  anomalies  that  are  less  than  strabismus, 
he  discusses  Von  Graefe's  Insufficiency  of  the  interni  and  the  sacra- 
fice  he  made  of  single  vision,  for  a  distance,  for  convergence,  for 
reading  distance;  by  an  operation  he  made  that  condition,  declaring 
that  his  doctrine  of  obtaining  fusion  at  one  point  at  the  expense  of 
another  point,  would  not  be  tolerated  in  these  days. 

He  holds  that  in  the  introduction  of  his  system  of  heterophoria, 
he  gave  expression  to  new  facts  by  new  terms.  In  a  series  of  cases, 
reported  to  the  Royal  Academy  of  Medicine  in  Belgium,  1883,  for 
which  he  received  the  award  in  a  competition.  His  proposition 
was;  that"  difficulties  of  the  adjustment  of  the  eyes  are  a  source 
of  nervous  trouble,  and  more  frequently  than  other  conditions, 
constitute    a    nervous    tendencv." 


90  HAZEN'S   NEW   FINDINGS 

The  difference  between  Von  Graefe's  practice  on  adjustment  of 
the  eyes,  and  his,  was  that  the  former  did  not  establish  equilibrium 
for  all  points,  but  he  sought  that  result.  Jn  seeking  this,  the  practice 
ot  tenetomy  under  it  became  more  refined  and  more  scientific,  lie 
regards  his  instrument,  the  Tropometcr,  in  these  cases,  as  sheddinir 
a  flood  ot  [ighl  on  the  subject,  and,  for  a  time,  it  seemed  as  though 
a  key  had  been  found  to  unlock  secrets.  The  anomalous  position  of 
the  plane  of  vision  was  first  shown  by  it.  With  all  the  investiga- 
tions of  Helmholtz,  he  shows  that  the  true  investigations  of  the  sub- 
ject of  the  muscular  apparatus  had  not  yet  been  made.  His  in- 
struments for  technical  physiological  investigation  enabled  him 
to  make  a  class  of  examinations  better  than  all  that  had  gone  before. 

The  maintaining  of  the  uprightness  of  objects  seen  by  the  eye, 
is  one  of  the  important  impulses.  The  construction  of  the  muscles, 
which  roll  the  eye  upon  its  optic  axis,  is  an  element  of  cause  in 
exophoria;  that  when  the  rotation  of  the  eyes,  in  its  full  extent,  is 
understood,  it  will  no  longer  be  necessary  to  perform  tenotomy  for 
convergence  or  divergence  squint.  The  full  understanding  of 
heterophoria  and  its  bearing  on  the  nervous  system  fairly  con- 
stitute a  science. 

He  sees  that  oculists  will,  in  the  future,  hold  a  closer  relation 
to  the  physical  well  being  of  patients  in  correcting  bodily  postures, 
which  go  far  to  produce  ailments  from  pose  of  the  head  and  eyes. 

In  the  section  of  Physiology  of  the  eyes,  he  makes  a  close  study 
of  torsion,  the  w^heel  like  movement  on  and  around  the  plane  of 
regard,  making  a  distinction  between  this  and  declination.  "The 
angle  of  torsion  is  the  angle  of  displacement  of  the  vertical  meridian, 
when  the  eye  passes  from  a  primary  to  a  secondary  position." 
Displacement  to  the  temporal  side  is  positive;  to  the  median  side 
negative.  The  rotation  of  the  eye  is  about  a  fixed  point,  practically 
the  center  of  the  eye;  the  muscles  performing  it  are  divided  into 
three  pairs;  each  pair,  the  axis  of  which  cuts  the  center  of  rotation, 
acting  alone.  It  is  also  to  be  remembered  that  neither  eye  acts 
independently,  but  the  two  eyes  are  in  definite  relations  and  asso- 
ciation with  each  other.  The  attachments  of  the  different  muscles 
to  the  eye  ball  in  front,  being  varied  from  a  right  angle  to  the  axis 
of  action,  caused  deviations  from  the  normal  meridians.  The 
conclusion  is  that  the  action  of  the  muscles  upon  the  eyeball  cannot 
be  uniform.  In  the  associated  movements  of  the  two  eyes,  there  is 
also  often  a  noncomformity  of  motion  from  mal-insertion  of  the  mus- 
cles. In  the  combined  action  of  two  muscles  or  pairs  of  the  two 
eyes,  the  vertical  lines  are  thrown  out  of  parallelism. 


GEORGE  T.  STEVENS,  M.  D.  91 

In  the  combined  action  of  the  two  pairs,  displacements  may  be 
detected. 

A  turning  of  the  eye  upon  its  own  antcro-posterior  axis  by  direc- 
tion of  the  traction  of  the  superior  and  inferior  recti  and  the  oblique 
muscles  is  called  torsion.  The  torsion  which  tilts  the  upper  end  of 
the  vertical  meridian  to  the  nasal  side  is  negative  and  that  which 
tilts  the  upper  end  outward  is  positive.  The  compensating  action 
of  the  muscles,  when  in  health,  prevents  torsion. 

With  the  Clinoscope  the  vertical  lines  may  be  made  to  rotate 
20°  with  the  two  eyes.  The  horizontal  lines  cannot  be  rotated 
to  this  extent. 

ANOMALOUS  CONDITIONS  OF  THE  MOTOR  MUSCLES  OF 
THE  EYES,  CONSISTENT  WITH   THE   PHYSIO- 
LOGICAL STATE. 

Euthyphoria. — A  passive  adjustment  of  the  normal  plane  of 
vision,  such  that  this  visual  plane  is  coincident  with  the  plane  of 
the  horizon,  or  very  nearly  so. 

Axophoria. — A  passive  adjustment  of  the  normal  visual  plane, 
at  an  angle  distinctly  above  the  plane  of  the  horizon. 

Katophoria. — A  passive  adjustment  of  the  visual  plane  at  an 
angle  distinctly  below  the  plane  of  the  horizon. 

Anotropia. — An  adjustment  in  which  the  visual  line  of  either 
eye  deviates  upward  when  the  other  is  in  fixation. 

Katotropia. — An  adjustment  in  which  the  visual  line  of  either 
eye   deviates   downward   when  the  other  is   in  fixation. 

Orthophoria. — A  tending  of  the  visual  lines  in  parallelism. 

Heterophoria. — A   tending   of  these   lines   in   some  other   way. 

Esophoria. — A  tending  of  the  visual  lines  inward. 

Exophoria. — A    tending    of    the    visual    lines    outward. 

Hyperphoria. — R.  or  L. — A  tending  of  the  right  or  the  left 
visual  line  in  a  direction  above  its  fellow.  The  term  does  not  imply 
that  the  line  is  too  high,  but  that  one  is  higher  than  the  other. 

Tendencies  in  oblique  directions  are  expressed: 

Hyperesophoria. — A  tendency  of  one  visual  line  above  the  other, 
with  a  tendency  of  the  lines  inward. 

Hyperexophoria. — A  tendency  of  one  visual  line  above  the  other, 
with  a  tendencv  of  the  line  outward. 


92  HAZEN'S   NEW    FINDINGS 

1 1 1  terotropia. — R.  or  L. — A  deviation  of  the  visual  lines. 

Esotropia. — A  deviation  of  the  visual  line  inward. 

Exotropia. — A  deviation  of  the  visual  line  outward. 

Hypertropia.  (R.  or  L.) — A  deviation  of  one  visual  line  above 
the  other. 

IIyperesotropia.  A  deviation  of  one  visual  line  inward  and 
above  the  other. 

Hyperexotropia. — A  deviation  of  one  visual  line  out  and  above 
the  other. 

Declination. — He  tests  the  extent  of  the  rotation  of  the  eyes 
by  his  Tropometer  and  claims  that  before  this  instrument  there 
had  been  no  reliable  method  of  arriving  at  approximate  measure- 
ments of  all  the  rotations.  He  gives  standards  of  rotation.  On 
the  degree  of  anomalous  condition  depends  the  amount  of  disturb- 
ance of  the  nervous  system.  The  recognition  of  declinations  will 
mark  the  advance  in  the  character  of  the  results.  The  science  of 
declination  cannot  well  be  compared  with  that  of  heterophoria  as 
they  are  intimately  associated.  When  the  meridian  of  the  retina 
deviates  from  the  meridan  of  external  space  inwardly  or  outwardly, 
that  is,  when  the  ball  rolls  upon  its  visual  axis,  it  is  a  declination. 
When  the  top  of  the  retinal  meridan  leans  towards  the  temple  it  is 
positive  (plus)  declination;  Avhen  toward  the  nose,  negative  (minus) 
declination;  sometimes  these  declinations  occur  in  eyes  physiolog- 
ically correct,  and  are  as  various  as  errors  of  refraction  and  as 
important  in  tenotomies. 

Among  the  distinctive  symptoms  named  in  declinations,  are 
chronic  hyperemia  with  smarting  and  dryness,  caused  by  pressure 
of  the  lids  against  the  ball  in  the  endeavor  to  resist  the  tendency  to 
roll;  habitual  pain  in  and  over  the  brow,  of  one  or  both  eyes;  arching 
of  the  brow.     He  calls  his  detecting  device,  "The  Lens  Clinoscope." 

With  Myopia,  there  is  usually  a  high  degree  of  declination. 
Declinations  give  contour  to  the  expression  of  the  face,  in  arching 
brows.  It  is  easy,  not  only  to  recognize  the  class  of  declination  but 
to  tell  the  direction  of  the  leaning  of  each  eye.  The  habitual  pose 
of  the  head  and  indeed  that  of  the  body,  is  in  a  large  measure 
influenced  by  peculiarities  of  adjustment  of  the  eyes. 

He  dissents  from  the  doctrine  of  Donders,  so  generally  accepted, 
that  of  the  association  of  the  two  functions,  accommodation  and 
convergence  that  an  excess  of  the  action  of  one  should  cause  an 
excess  in  the   function  of  the  other.     "The  affections  of  the  ciliary 


GEORGE  T.  STEVENS,  M.  D.  33 

muscles  are  not  essential  factors  of  the  anomalies  of  the  motor 
muscles,  and  need  not  be  considered  beyond  the  reciprocal  influences, 
which  may  arise  from  habitual  associations."  Heterophoria  may 
be  regarded  in  general  a  resultant  of  declination.  As  the  accuracy 
of  estimation  of  distance  and  form  is  made  by  the  muscular  move- 
ments of  the  eye,  bringing  into  position  the  different  meridians 
over  retinal  spaces  in  their  relation  to  the  maclea,  and  that  these 
adjustments  are  made  with  inconceivable  rapidity  and  frequency, 
it  is  important  to  know  the  degree  which  a  pair  of  eyes  has  to  make 
up  by  its  want  of  equilibrium,  thereby  estimating  the  nervous 
force  expended  in  ariy  particular  occupation.  Heterophoria, 
in  one  person  might  not  produce  disturbance,  but,  under  different 
circumstances  cause  trouble;  another  person  with  very  little  devia- 
tion might  suffer  severely  when  called  upon  in  duties  that  demand 
unusual  hours;  so  that  a  certain  degree  of  fault  in  the  associated 
movements  will  not  denote  the  degree  of  nervous  disturbance,  or 
that  when  there  has  been  no  inconvenience  from  the  use  of  eyes, 
that  there  is  a  well  balanced  adjustment. 

This  would  indicate  that  the  time  to  correct  anomalies  is  before 
the  disturbance  occurs  and  if  there  is  such  a  condition  that  entails 
great  expenditure  of  nervous  energy,  it  should  be  corrected  before 
a    breakdown    is    brought    about. 

Tests. — Among  the  ''Auxiliary  Tests  of  the  Phorometer,"  he 
cites  duction.  This  he  calls  overcoming  difficulties  in  the  fusion  of 
images.  The  measure  of  it  is  the  strength  of  prism,  which  the  eyes 
can  overcome.  Von  Graefe  named  adbuction  and  adduction,  and 
sursumduction,  right  and  left,  which  is  overcoming  prisms  base 
down  over  R.  E.  and  is  Right  sursumduction;  the  same  position 
over  L.  E.  is  Left  sursumduction.  The  same  terms  apply  if  prism 
is  reversed  before  the  opposite  eye. 

The  ability  in  adduction  with  orthophoria  is  50  base  out.  Prac- 
tice and  acquiring  a  "knack"  will  give  such  ability  but  there  is  no 
fixed  standard.  It  is  necessary  that  the  prisms  be  placed  equally 
before  the  two  eyes.  Not  so  in  abduction  with  base  in,  but  may  be 
placed  over  either  eye.  He  placed  a  standard  of  8  in  ab- 
duction. These  collateral  tests  are  less  in  demand,  since  the  dis- 
covery of  the  Clinoscope,  yet  are  not  to  be  ignored.  He  regards 
the  vertical  diplopia  test  at  the  reading  distance  of  no  absolute 
value.  He  depends  much  upon  the  screen  and  the  parallax  test 
of  Duane. 

Esophoria  "is  not  to  be  regarded  a  disease  or  as  a  weakness, 
nor  yet  a   spasm."     "It  is   a   physiological  state,  depending  upon 


94  HAZEX'S  NEW   FINDINGS 

anatomical  peculiarities  of  the  course  and  the  insistence  of  the 
motor  muscles,  by  which.. ..the  balance  of  tension  is  normally 
toward  the  median  plane."  In  exophoria  as  in  esophoria  the  habit- 
ual visual  state  is  the  union  of  the  images  of  the  two  eyes.  When 
diplopia  occurs  the  deviating  tendency  has  passed  to  actual  devia- 
tion, and  then  exotropia.  Exophoria  in  accommodation,  which 
is  a  condition  analogous  to  insufficiency  of  the  intern i  of  Von  Graefe 
— not  a  condition  of  true  exophoria. 

In  hypcrophoria  single  vision  is  assumed  although,  when  a  single 
degree  exists,  subjects  of  the  affection  surrender  to  it.  Xo  hete- 
rophoria  exerts  more  disturbing  injurious  influences,  giving  rise  to 
fatigue,  perplexity  and  it  exaggerates  all  other  tendencies.  It  has 
a  slight  deviation  effect  on  type  and  its  doubling  effect  causes 
inordinate  muscular  tension  or  a  suppression  of  the  images  of  ,qne 
of  the  eyes.  Amblyopia  is  not  only  common  in  hyperphoria  but  it 
is   uncommon   to  find   hyperphoria   without   amblyopia. 

Expression  of  the  face  and  the  bodily  pose  are  sufficient  indica- 
tion, in  some  forms  of  anaphoria,  to  indicate  a  restricted  chest  and 
that  the  respiratory  passages  are  partly  shut  in  a  valve  like  fashion. 
Although  they  may  not  acquire  phthisis,  the  pains  in  the  back  of 
the  neck,  in  the  middle  dorsal  region,  and  even  in  the  lumbar 
region  are  often  the  physical  protest  against  tension  upon  the  mus- 
cles of  these  parts 

"Weakness"  of  certain  muscles  is  not  the  cause  of  different  forms 
of  heterophoria.  The  most  conspicuous  cause  is  in  the  vertical 
meridian.     Declinations  are  peculiarities  of  tendon  insertions. 

The  following  is  the  method  given  for  the  manipulation  of  prisms 
in  effecting  direction  of  the  muscles.  The  simplest  and  easiest, 
and  indeed  the  most  effective  way  of  making  these  tests  is  by  help 
of  prisms,  taken  from  the  trial  case.  For  abduction,  take  a  prism, 
for  example  of  5°  from  the  box,  and  place  it  with  its  base  toward  the 
nose,  close  to  one  eye  of  the  patient,  and  ask  him  to  unite  the 
images,  if  two  result.  If  this  can  be  done,  proceed  to  the  next 
grade  or  pass  over  one  or  two  grades  and  try  again.  In  a  very  few 
trials  the  limit  will  be  reached.  On  the  other  hand,  if  the  5°  cannot 
be  overcome,  a  lesser  grade  is  tried,  and,  if  necessary,  other  lesser 
ones  until  a  union  of  images  can  be  found.  The  strongest  prism 
that  can  be  overcome  is  the  measure  of  abduction.  If  there  is 
actual  convergence  it  may  require  a  prism,  base  out,  to  enable  the 
patient  to  unite  the  images.  Then  there  is  homonymous  diplopia 
of  the  degree  of  the  weakest  prism  that  will  unite  the  images. 
Prisms  of  much  less  grade  are  usually  required  for  sursumduction. 
A  prism  of  one,   two  or  three  degrees  is  usually  sufficient.     Place 


GEORGE  T.  STEVENS,  M.  D.  95 

the  prism,  with  the  base  down,  before  one  eve.  If  this  can  be 
overcome,  present  a  stronger  one,  until,  with  no  stronger  one  will 
the  images  unite.  In  most  cases,  a  prism  of  not  more  than  3°  may 
be  overcome.  In  myopic  caess  with  high  declinations,  prisms  of 
9°  or  10°  may  be  overcome.  After  determining  the  sursum- 
duction  in  one  direction,  in  a  few  minutes  the  prisms  can  be  placed 
over  the  other  eye,  base  down  as  before,  or  over  the  first  eye  with 
base  reversed. 

After  thus  testing  in  the  different  forms  of  heterophoria,  tests 
are  made  of  the  rotation  by  his   Tropometer,   then   the   Clinoscope. 

Esophoria,  which  occurs  in  the  proportion  of  more  than  three  to 
one  of  exophoria,  plays  an  important  role  as  a  cause  of  neurosis. 
When  the  strain  in  adjusting  the  eyes,  in  close  work,  may  be  ex- 
pressed in  the  orbit  and  localized  in  the  muscles  in  case  of  exophoria. 
The  reaction,  in  case  of  esophoria,  is  found  after  direction  on  a 
distant  point,  as  upon  attending  church,  theatre  or  picture  gallery, 
when  the  eyes  have  been  directed,  during  a  considerable  time,  in 
parallelism.  The  pain  is  at  the  back  of  the  head  and  upper  part 
of  the  neck,  causing  a  general  malaise  and  sense  of  illness. 

The  amount  of  deviation  is  not  commensurate  with  the  irritating 
result. 

The  suppression  of  the  false  image  gives  relief,  afforded  at  ex- 
pense and  perplexity  of  another  sort.  Of  a  large  number  of  cases, 
which  go  from  one  oculist  to  another,  in  hope  of  relief,  and  submit 
to  an  almost  endless  change  of  spectacles  with  1  ittle  advantage,  a 
very  considerable  number  have  slight  grades  of  esophoria.  These 
moderate  cases  of  esophoria  may  represent  declinations,  and  it  is 
this  to  which  nervous  perplexity  is  due  rather  than  the  esophoria. 
In  a  certain  proportion  of  cases,  accommodation  is  feeble,  pupil 
sluggish  and  dilated.  Attention  is  to  be  turned  to  the  declination, 
which  may  induce  the  esophoria. 

Amblyopia  is  rather  the  rule  than  the  exception  in  hyperphoria. 
In  esophoria  at  least,  it  is  quite  common  to  have  but  one  third  of 
the  visual  power  in  one  eye. 

Nutrition  of  the  eye  is  interfered  with  in  heterophoria;  the 
crystalline  lens  and  tunics  of  the  eye  are  affected.  The  discovery 
of  causes,  which  induce  perverted  nerves,  is  more  practical  than 
volumes  of  profound  ambiguity.  Muscular  anomalies  are  etiolog- 
ical factors  in  many  forms  of  eye  diseases;  blepharites,  conjuncti- 
vitis, corneal  ulcers.  A  large  class  of  people,  who  are  suffering 
from  "malaria,"  "biliousness",  "nervous  prostration,"  "dyspepsia," 
"constipation,"  etc.,  are  simply  paying  the  penalty  of  uncorrected 
heterophoria. 


96  HAZEN'S  NEW  FINDINGS 

The  influence  of  Anaphoria,  Kataphoria  and  declination  in  dis- 
eases of  the  eyes,  as  trachoma,  and  in  respiratory  diseases  is  dis- 
cussed at  length.  Facial  expression,  taken  on  from  condition  of 
the  eye  muscles  in  heterophoria,  and  declination  occupies  consider- 
able space  in  analyzation. 

TREATMENT. 

TREATMENT  OF  DECLINATION.  Under  certain  circum- 
stances, spherical  and  cylindrical  glasses,  prismatic  lenses  will 
have  an  influence  in  correcting  declinations;  no  practical  use  oJ 
them  can  be  made  in  the  treatment  of  this  class  of  anomalies. 
Strong  convex  lenses  in  neutralizing  declination  may  have  temp- 
orary effect  as  in  strabismus  but  not  in  the  relief  of  the  ciliary 
muscles.     Gymnastics  are  not,  in  any  sense,  curative. 

Surgical  Treatment  of  Declination. — Treatment.  1st.  Gen- 
eral. All  the  heterophoric  conditions  are  depending  on  anatomical 
peculiarities,  and  cannot  be  changed  by  medical  or  other  treatment, 
directed  to  general  physical  conditions,  but  temporary  benefit 
may  result  from  treatment  of  this  nature.  Often  the  expense  of 
ocular  adjustments  is  greater  than  the  victim  can  afford,  and  the 
result  is,  economy  of  nervous  energy — rest.  During  this  suspen- 
sion the  general  physical  tone  may  so  greatly  improve  that  dis- 
turbances to  health  may  be  lost  sight  of  for  a  time.  The  anomaly 
is  not  removed.  Tonics,  change  of  air,  abundant  wholesome  food, 
to  establish  the  general  vigor  of  the  nervous  organization,  consti- 
tute the  principal  means  for  re-establishment  of  the  nervous  organi- 
zation. 

Electricity  as  a  local  stimulant,  may  induce  a  change  of  nutri- 
tion. 

He  condemns  the  coal  tar  preparations,  as  chloral,  sulphoral,  etc. 

They  are  paralyzers  of  the  nuclear  region,  supplying  the  nerves 
of  the  eye  muscles  and  give  temporary  relief  at  the  expense  of  more 
lasting  injury. 

As  direct  agents  for  the  relief  of  functional  disturbances,  prisms 
are  used,  both  as  a  means  for  gymnastics  and  in  spectacles.  He 
says  he  formerly  gave  much  attention  to  exercise  of  the  muscles 
and  it  was  the  means  of  relieving  many  of  my  earlier  reported  cases. 
The  method  of  using  prisms  in  gymnastics  is  thus  described.  A 
patient,  looking  at  the  flame  of  a  candle  at  20  feet  distant,  a  weak 
prism  is  placed,  base  out,  before  one  eye — as  soon  as  the  images 
unite,  an  equal  prism,  with  its  base  out,  is  placed  before  the  other 


GEORGE  T.  STEVENS,  M.  D.  97 

eye.  As  fast  as  images  are  united  this  alternate  addition  of  prisms 
is  continued,  until  it  is  no  longer  convenient  to  add  them,  or  until 
the  patient  fails  to  unite,  Then,  if  union  cannot  take  place,  the 
prisms  are  removed  and  the  same  process  is  repeated  until  more 
can  be  accomplished  if  possible.  If  the  patient  is  able  to  unite 
these  weak  prisms,  the  surgeon  begins  with  those  of  higher  grade, 
adding  alternately  until  the  images  are  no  longer  united.  This 
also,  is  repeated  several  times,  and  thus  adding  ability  can  be  raised. 
A  similar  method  can  be  used  in  overcoming  by  abduction,  the  prism 
being  placed  with  its  base  in.  In  this  case,  it  is  rarely  required 
to  add  one  prism  above  another  before  both  eyes — a  single  prism 
before  one  eye  serving  the  purpose. 

Gymnastics  for  declination  can  be  done  by  use  of  Maddox  rod 
twisted  from  a  horizontal  position,  but  to  get  at  the  rotations,  the 
Clinoscope  is  necessary.  The  use  of  low  degrees  of  prisms  in  spec- 
tacles, correcting  only  a  portion  of  the  deviation,  was  carried  on 
by  him  to  a  large  extent,  at  one  time,  but  he  found  a  very  few  who 
derived  important  relief,  and  a  smaller  number  still  who  found 
permanent  relief.  He  found  better  success  in  cases  of  anaphoria 
and  kataphoria,  using  prisms  of  equal  strength  on  both  sides. 
Strabismus  occurs  because  one  or  more  of  the  muscles  of  the  eye  is 
disabled  or  because  there  is  some  mechanical  obstruction  of  the 
free  movement  of  one  or  both  eves  in  certain  directions. 


We  have  given  much  space  to  the  review  of  Dr.  Howe's 
two  volumes  on  the  muscles  of  the  eye.  1st.  Because 
it  is  a  late  production.  2nd. — Because  the  principal 
characteristic  of  the  work  is  the  thorough  analyzation 
of  the  subject  and  classification  of  its  minute  subdivi- 
sion and  their  presentation.  3rd. — It  thoroughly  repre- 
sents the  general  status  of  the  subject,  in  our  time. 


1907. 


LUCIEN  HOWE,  M.  A.,  M.  D. 

Professor     of    Ophthalmology,     University     of     Buffalo,    etc. 

THE  MUSCLES  OF  THE  EYE. 
2  Volumes. 

After  considering  the  anatomy  of  the  eye,  he  gives  the  plan  of 
study  of  the  physiology  of  the  organ,  and  comes  to  the  conclusion 
that  for  "comfortable  binocular  vision,  especially  at  the  working 
distance,  a  relation  within  certain  limits  must  be  maintained 
between  accommodation  and  convergence  and  torsion."  The  geome- 
try of  the  globe  is  considered.  Listing's  plane  the  center  of  motion; 
the  angles,  Alpha,  Delta  and  Gamma  and  their  clinical  importance. 
The  relation  of  the  visual  acuity  of  the  action  of  the  eye.  "The 
position  that  the  globe  assumes  is  determined  by  the  sensibility 
at  the  fovea  is  so  much  greater,  there  is  an  instinctive  desire  to  turn 
the  eye  that  the  central  part  of  the  image  shall  fall  just  at  that 
point."  "The  smallest  space  between  the  points,  which  can  be 
perceived,  must  subtend  an  angle  of  about  55  seconds" — a  fact 
on  which  Test  Type  is  constructed.  For  testing  at  this  near  point, 
"it  is  desirable  to  use  types  for  expression  in  meters  or  fractions 
of  a  meter,  if  we  are  to  make  this  part  of  Ophthalmology  accord 
with    the    rest." 

"The  normal  eye  is  accustomed  to  suppress  those  images,  which 
do  not  fall  on  the  fovea  to  such  an  extent  that  we  are  unconscious 
of  it."       "It  is  sometimes  the  images  of  one  eye   that    predominate, 


100  HAZEN'S   NEW   FINDINGS 

sometimes  those  of  the  other,  and  so  .long  as  wc  can  see  in  a  part 
of  the  \  isual  tic-Id  images  of  one  eye,  those  of  the  other  eye  are  com- 
pletely suppressed."     7 'scheming. 

"This  lias  an  important  bearing  upon  some  forms  of  deviation 
with  which  we  have  to  deal."  "Observations  indicate  that  the 
tendency  of  a  single  eye,  when  at  rest,  is  to  swing  from  the  primary 
position — sometimes  inward,  or  more  frequently  outward,  or  out- 
ward and  upward."  "We  constantly  find  ,in  practice,  a  slight 
degree  of  latent  convergence  or  esophoria."  "In  sleep,  the  eye 
assumes  a  position  of  up  and  outward."  Blind  eyes,  it  is  said, 
"almost  invariably  turn  outward,"  but  this  is  not  quite  true.  The 
examination  of  21  pupils  of  the  N.  Y.  State  school. for  the  blind, 
showed  that  there  were  almost  as  many  of  abnormal  convergence 
as  of  divergence.  "We  must  conclude  therefore,  that  the  mono- 
cular position  of  rest  seldom  corresponds  to  the  primary  position." 

Accommodation. — Range  of  accommodation  indicates  "the 
amount  of  accommodation  of  which  an  eye  is  capable."  When 
Test  Letters  are  well  constructed  and  reduced  to  proper  size,  it 
is  much  more  convenient.  The  many  methods  of  investigation 
of  the  pupillary  reaction  are  so  poorly  adapted  to  clinical  use  that 
practitioners  do  not  avail  themselves  of  them.  In  youth,  15  to 
20  years,  the  pupil  is  about  4.1mm  and  at  50  years,  about  3mm. 
The  main  causes  which  produce  changes  in  its  diameter  are — 1st. 
Intensity  of  illumination.  2nd.  Act  of  accommodation  contracts. 
3d.  Size  relates  to  respiration  and  circulation.  4th.  "Varying 
conditions  of  the  nervous  system — especially  those  involving  the 
sympathies,  fear,  surprise,  emotion"  and  the  more  lasting  changes 
from  lesions  of  the  motor  oculi.  He  uses  a  modified  miscroscope 
with  a  micrometer  eye-piece. 

ASTIGMATIC. 

Irregular     Contraction     of     the     Ciliary     Muscle. 

From  the  irregular  action  may  be  established — 1st.  Facts  of 
anatomical  arrangement — 2nd.  In  other  muscles  exact  measure- 
ments show  a  different  degree  of  tension  of  different  fibres — 3rd. 
"Certain  branches  of  the  3d  nerve  are  sometimes  paretic  or  'in- 
sufficient, leaving  muscles  supplied  by  other  branches  in  an  entirely 
normal  condition."  4th.  The  action  of  the  ciliary  to  overcome 
astigmatism  in  the  consulting  room,  contradiction  is  found  between 
the  declaration  of  the  patient,  on  looking  at  the  charts,  and  what 
is  found  by  scientific  examination.  5th.  Sensation  of  the  patient, 
headache,  and  its  relief  on  correction. 


LUCIEN  HOWE,  M.  D.  101 

ONE    EYE  IN  MOTION. 

Nomenclature. 

Adduction.  Intorsion. 

Abduction.  Extorsion. 

Superduction.  True  torsion. 

Subduction.  False  torsion. 

Cirsumduction,  or   Cycloduction. 

Ophthalmotropes  are  models  of  mechanisms  to  produce  the  motions 
of  the  eyes  and  in  great  variety.  It  assists  the  teachers  in  con- 
veying the  fundamental  ideas  concerning  the  movements  of  the 
balls  by  the  ocular  muscles.  "All  the  points,  which  an  eye  can  see 
or  fix,  while  the  head  remains  immovable,  constitute  the  field  of 
fixation  or  the  motor  field."  "Most  physiologists  and  clinicians 
have  depended  on  the  perimeter  for  measuring  this.  "It  is  impor- 
tant to  remember  that  the  limit  of  the  field  of  fixation  is  not  to 
be  judged  entirely  by  the  number  of  degrees  which  an  eye  can  turn 
in  any  given  direction.  Much  also  depends  upon  the  manner 
in  which  that  motion  is  made."  We  wish  to  know,  for  instance,  in 
abnormal    convergence: 

1st.     Does  any  deviation  of  one  or  both  eyes  exist? 
2nd.     Which    eye — if   either,    is    specially    affected? 
3d.      Exactly  which  muscle  or  group  of  muscles  is  affected? 
4th.      Is  the  deviation  due  to  excessive  contraction  of  the  adductors, 
(action  esotropia)  or  to  paresis  of  the  abductors  (passive  eso- 
tropia) or  is  it  due  to  both  causes?" 
As  to  the  1st.     Deviations  are  not  always  apparent — they  may 
be  latent  and  this  is  shown  sometimes  by  the  behavior  of  the  eye 
as  it  approaches   the  limits.     2nd.     "Most  of  the  tests  with  double 

images do    not    show    which    eye"    has    the    difficulty.     3rd. 

The  limits  of  field  assist  in  locating  the  group  of  muscles  or  even 
the  principal  muscle.  4th.  It  is  difficult  to  decide  and  require 
aid  in  other  ways.  The  lifting  power  of  the  adductors,  when  looking 
at  a  distance,  averages  about  18  grams.  This  should  not  be  con- 
fused with  the  tensile  strength — that  is  the  weight  which  a  muscle 
will  sustain  without  breaking — 2  to  2  and  14  -Kilos  which  is  several 
times  greater  than  that  of  the  ordinary  muscular  fibre."  The 
rapidity  of  the  lateral  motion  of  the  eye  as  found  by  photograms 
is  that  it  requires  fifty  to  sixty  thousandths  for  30  degrees,  and 
about  100  thousandths  for  one  100th  of  a  second  for  100  degrees. 
In  the  act  of  reading  from  left  to  right,  the  eye  stops  four  or  five 
times  for  perhaps  5  or  10  thousandths  of  a  second.  The  movements 
of   the   eye,    while   reading,    are   shown    by    the   photogram — at   the 


L02  HAZEN'S   NEW    FINDINGS 

end  of  the  line  the  eye  rests   for  a   varying  length  of  time,   then 
swings    back    to   the   left    and    begins    again. 

In  winking  the  average  time  taken  is  about  a  half  second.  The 
time  of  remaining  closed  is  about  two  to  three  tenths  of  a  second. 
The  lid  is  raised  more  slowly  than  it  is  closed — occupying  from 
one  i"  two  tenths  of  a  second.  When  one  eye  is  slower  than  the 
other  in  its  movements,  it  may  be  the  first  indication  of  a  muscular 
paralysis.  A  wheel  motion  of  one  eye  only  is  possible,  but  is  un- 
usual and  is  of  no  practical  importance.  Contrary  to  Maddox 
in  regard  to  the  silence  of  the  eye  muscles  when  in  motion,  Herring 
is  quoted  as  saying,  "that  several  proficient  auscultators  were 
able  to  tell  when  the  eyes  were  looking  at  a  distance  or  converging, 
by  the  sound  produced." 

DIVISION  1. 
BOTH  EYES  AT  REST. 

The  relation  of  one  eye  to  the  other  and  the  fundamental  prin- 
ciple, which  controls  all  associated  action,  must  be  taken  into  ac- 
count. As  nature  abhors  a  vacuum,  so  is  the  desire  for  single  vision. 
"The  associated  motion  of  two  eyes  requires,  first  of  all,  that  the 
image  of  an  object  looked  at,  shall  fall  on  parts  of  the  two  retinas 
which  correspond  to  each  other. "The  measurement  of  the  inter- 
ocular  base  line,  which  is  the  distance  between  the  centers  of  the 
eyes,  or  pupils  of  the  eyes,  is  a  practical  necessity  for  several  reasons. 
The  Primary  position  is  when  the  visual  axes  of  the  horizontal 
plane  are  parallel  to  each  other  and  perpendicular  to  the  line  joining 
the  centers  of  the  two  eyes.  The  different  forms  of  heterophoria 
are,  "essentially,  passive  conditions."  When  we  "disassociate 
the  retinal  image  in  one  eye,  from  its  fellow  eye,  each  globe  tends 
to  swing  into  the  position  most  natural  to  it."  Then  if  single 
vision  is  maintained  in  heterophoria,  it  requires  a  constant  effort 
of  one  or  more  groups  of  muscles  to  maintain  single  vision. 

The  essentials  for  examination  are — room,  of  six  meters  in  length, 
darkened,  and  light  placed  at  six  meters  or  more.  A  candle  flame 
s  inconvenient  and  inaccurate,  but  if  used,  should  be  inclosed  in 
an  opaque  cylinder,  with  circular  spring  on  one  side,  and  a  head 
rest  to  keep  the  head  in  proper  position.  The  Maddox  rod  is  an 
admirable  test  in  many  respects.  A  Phorometer  in  connection 
with   head  rest  is  necessary  for  exactness. 


LUCIEN  HOWE,   M.   D.  103 

DIVISION  II. 

CLASSIFICATION  OF  TESTS. 
1st.  Group. 

1st.     Displacement  of  the  clear  image  of    one    eye,  up  or  down. 

(a)  As   Von  Graefe's   single   prism,   base   up   or   down. 

(b)  Stevens,  Savage  and  others — two  prisms,  one  base  up,  and 
the  other  down — one  over  each  eye. 

(c)  Maddox  double  prism,  bases  joined. 

2nd.     Group. 

The  image  is  clear  in  one  eye,  but  in  the  other  is  so  disturbed  or 
blurred  that  the  desire  for  vision    is  abolished. 

(a)      Maddox  rod.      (b)      Stenopaic  Lens.       (c)      Cobalt   glass. 

3rd.  Group. 

The  Screen  test — blinding  one  eye  and  noting  whether  the  eye  screened 
swings   away    to    another   point   of  rest. 

Instruments  must  be  constructed  so  that  they  can  be  arranged 
exactly  in  the  same  position.  Much  greater  exactness  is  necessary 
before  we  can  lessen  materially  the  existing  confusion  concerning 
muscular  statics.  The  ciliary  muscle  is  an  important  factor  in 
determining  the  position  of  the  visual  axis.  In  hypermetropia 
there  is  some  tension  of  that  muscle  in  seeing  distant  objects  clearly. 
Results  will  be  less  conflicting  if  atropia  is  used  and  a  correction 
of  the  refraction  is  made.  "The  recti  muscles  influence  the  static 
condition  of  the  visual  axes,  for  after  atropia  and  correction  of 
ametropia  there  is  movement.  The  condition  of  the  retina  in- 
fluences this  also,  for  it  is  sometimes  difficult  for  individuals  to 
perceive  the   image." 

The  so  called  "Position  of  Rest"  is  either  apparent,  which  is 
simply  a  relaxation,  more  or  less  complete,  of  the  extra  ocular- 
muscles,  or  actual  .which  is  relaxation  of  both  intra-ocular  and 
extra-ocular  muscles.  The  results  obtained  in  examination  of  large 
numbers  of  persons  were  striking  in  showing  that  orthophoria  was 
by  no  means  necessary  to  comfortable  vision  as  had  formerly 
been  supposed.  The  methods  ordinarily  used  for  determining 
the  static  position  of  the  visual  axes  are  not  altogether  satisfactory. 

DIVISION  III. 
POSITION  OF  THE  VERTICAL  AXES. 

There  may  exist  a  tendency  of  the  vertical  axes  to  revolve  about 
the    anterior-posterior    axes.     When    the    eyes    arc    in    a    primary 


104  HAZEN'S  NEW  FINDINGS 

posiii"ii  the  vertical  axes  tend  to  diverge  upward,  at  an  angle  with 
each  other  of  about  three  degrees.  The  fact  that  the  vertical 
axes  do  revolve  about  the  anterior-posterior  axes  is  important  and 
what  is  called  true  torsion. 

Tl  sis. 

The  double  prism  and  elaborated  by  Savage. 

The  Steven's  Clinoscope  &  Yolkmann's  Disks. 

The    adaption    of    Yolkmann's    Disks  to  Converging    Clinoscope. 

Test  for  Cyclothoria. 

The  double  prism  is  the  simplest  and  the  most  easily  understood 
but  it  is  not  exact.  The  Clinoscope,  with  intelligent  patients,  is 
most  exact.  (One  and  one-half  to  two  degrees,  each  eye.)  By 
tipping  the  upper  radius  out  four  degrees  to  allow  for  the  normal 
outward  tipping — then  count  any  variation  as  real  cyclophoria. 
It  is  better  to  use  the  terms,  outward  and  inward,  than  plus  and 
minus. 

Both  Eyes — Associated  Movements. 

The  motions  of  one  eye  alone  include  much  which  relates  to 
both.  The  two  eyes  may  be  regarded  as  the  halves  of  a  single 
organ.  In  order  to  avoid  double  vision,  each  eye  instinctively 
turns  its  visual  axis  to  the  point  to  which  attention  is  directed. 
Although  the  theories  of  the  mechanism  of  the  motor  impulses 
relating  to  both  of  the  eyes  in  the  same  direction,  have  been  dis- 
carded, our  knowledge  of  the  functions  of  the  cells  in  the  muscles 
in  different  portions  of  the  brain,  has  grown  more  exact.  There 
are   at  least  six  conjugate   innervations. 

Classification  of  Associated  Movements. 

1st.  A  torsional  movement  is  made  about  the  visual  axis,  which 
is  the  hub  of  the  wheel  motions.  These  motions  are  very  limited 
but  must  be  considered  in  connection  with  true  torsion,  which 
accompanies  convergence.  They  are  a  cycloduction-active.  Man}' 
devices  have  been  made  to  measure.  The  method  of  Herring  is 
described  as  simple — Donders'  Isoscope — his  own,  using  the  Mad- 
dox  rod  principle.  The  Maximum  and  Minimum  extorsion  and 
intorsion  is  found  to  be  in  a  limited  number  examined — Maximum 
extorsion  4°  and  Minimum  intorsion  21/?.  The  Maximum  extorsion 
and  intorsion  are  often  more  than  twice  as  much  as  the  Minimum, 
and  vary  greatly  in  different  persons.  The  importance  of  this 
studv   is   variouslv   estimated.      "The    evidence   is   abundant  where 


LUCIEN  HOWE,  M.  D.  105 

the  axes  of  astigmatism  approach  each  other,  but  are  still  suf- 
ficiently divergent  to  produce  this  effect  at  torsion.  That  condition 
is  a  very  important  cause  of  asthenopia,  although  the  degree  of 
astigmatism  be  slight." 

2nd.  "The  parallel  visual  axes  move  in  one  of  the  principal 
meridians  to  the  right,  left,  up  or  down.  There  is  no  torsion. 
The  clinical  bearing  in  this  connection  is  with  the  double  images 
in  paralysis." 

3rd.     The  parallel  visual  axes  move  obliquely.     The  vertical  and 
horizontal  axes  appear  to  change  their  position,  called  "false  torsion, 
by    Maddux.      Before    him,    it    was    described    simply    torsion.      It 
is   not  a   true  wheel  motion,  as  shown  by  detailed  descriptions  by 
different  authors.     This   also   has   a   bearing  in   cases  of  paralysis. 

4th.  The  visual  axes  do  not  remain  parallel  but  converge.  In 
doing  so  the  upper  end  of  each  vertical  axes  rotates  slightly  outward, 
producing  true  torsion. 

Convergence  is  the  most  important  group  of  motions  with 
which  we  have  to  deal,  as  it  is  accompanied  with  a  certain  amount 
of  Accommodation,  and  of  true  torsion.  We  now  estimate  it  by 
the  meter  angles  of  Nagel.  He  gives  a  table  of  the  degrees  of  con- 
vergence expressed  in  meter  angles  of  the  different  pupillary  dis- 
tances from  one  to  twenty  degrees. 

The  Relative  Fusion  Power  of  the  Muscles. 

The  power  of  the  abductor  muscles  is  found  by  placing  prisms, 
base  out,  before  one  or  both  eyes,  the  effort  being  to  avoid  double 
vision.  One  or  both  eyes  turn  in.  As  this  effort  is  one  exerted 
in  relation  to  the  opposing  groups  of  muscles,  we  can  properly  call 
it  the  relative  power  of  adduction.  It  depends  upon  two  factors; 
the  actual  strength  of  the  recti  muscles  and  the  so  called  instinctive 
desire  for  fusion.  Both  of  these  vary  in  different  individuals. 
The  same   principle   applies   to   all   ductions. 

How  To  Measure  Fusion  Power. 

If  the  parallel  visual  axes  are  directed  to  a  distant  object,  and 
a  prism  is  held  before  the  right  eye  with  the  base  out,  then,  as  the 
ray  from  the  light  passes  through  the  prism  is  deflected  towards 
its  base,  the  image  of  the  light  falls  not  on  the  fovea  of  the  rit'ht 
eye,  but  on  its  outer  side  and  crossed  diplopia  results;  with  an  in- 
stinctive desire  to  overcome  it,  the  eye  turns  far  enough  inward 
to   overcome   the   diplopia;    with    a    stronger    prism    the    eye    turns 


106  IIAZK.VS    NKW    KIN  DINGS 

in.  and  still  more  until  the  strongest  prism  is  reached  which  the 
adductors  can  overcome.,  which  is  said  to  represent  the  power  of 
adduction  of  that  pair  ot  eyes.  We  are  very  far  from  agreeing  on 
the  interpretation  of  the  data  obtained  by  this  simple  procedure. 
We  have  most  confused  the  idea  of  how  the  power  of  adduction 
should  be  measured — what  its  amount  is  in  normal  conditions,  and 
what  its  value  is  clinically,  and  indeed  whether  such  examinations 
have  any  value  at  all. 

Methods  of  Examinations. 

Let  us  begin  by  placing  a  prism  of  five  degrees  ,base  out  before 
the  right  eye.  Suppose  the  eye  overcomes  this  prism  and  others 
of  gradually  increasing  strength,  as  they  are  selected  from  the  trial 
case  until  we  find  at  last  that  one  of  nine  degrees  represents  the  total 
abducting  power,  or  we  may  begin  with  prisms  of  12  or  14  , 
taken  again  from  the  test  case  and  decreasing  from  that  point, 
find  again  that  one  of  nine  degrees  is  the  strongest  which  the  adduc- 
tor muscles  can  overcome.  If  however,  we  vary  that  method  of 
testing,  by  gradually  increasing  the  strength  of  the  prism,  without 
allowing  the  eye  an  interval  in  which  to  rest — the  result  is  different. 
If  we  use  the  prisms  in  series,  the  adduction  can  be  brought  to  ten 
or  twelve,  and  if  we  use  rotating  prisms,  adduction  can  be  brought 
to  fifteen  or  eighteen,  and  occasionally  greater.  Evidently,  we 
have    different    results,    dependent    upon    different    methods. 

1st.  The  Minimum  relative  of  fusion  power  of  a  group  of  muscles, 
is  that  which  wre  obtain  by  placing  different  prisms  before  the  eye, 
leaving  a  considerable  interval  between  the  tests,  or  it  is  that 
which  is  found  when  we  pass  from  a  prism  strong  enough  to  pro- 
duce  diplopia   to  one  which   can   be  overcome. 

2nd.  The  Maximum  relative  of  fusion  power  of  a  group  of  mus- 
cles is  that  which  we  obtain  when  we  pass,  by  gradual  increment, 
from  a  prism,  which  is  not  strong  enough  to  produce  diplopia  to 
one  which  cannot  be  overcome.  It  may  be  observed  that  this 
"development"  of  the  latent  heterophoria  is  something  which  may 
be  done  by  almost  any  one  who  has  abnormal  eyes,  if  he  will  take 
the  trouble  to  use  prisms  of  increasing  strength,  regularly  and  pa- 
tiently, even  for  a  comparatively  short  time.  Such  experiments,  on 
normal  or  abnormal  eyes,  show  how  readily  the  muscular  power 
can  be  increased,  and  indeed,  np  limit  within  the  bounds  of  cre- 
dulity, seems  to  have  been  placed  on  the  power  of  fusion.  In  a 
word,  the  maximum  of  fusion  power  is  of  some  interest  for  the 
sake  of  comparison,  but  certainly  is  not  of  as  much  importance 
in  itself,  as  many  writers  on  the  subject  would  have  us  think. 


LUCIEN   HOWE,   M.   D.  107 

Balance  of  Power. 

It  should  not  be  inferred  that  relative  weakness  in  a  certain 
group  of  muscles,  as  measured  in  terms  of  prisms,  is  an  indication  of 
inability  of  that  group  of  muscles  to  do  its  work  in  a  physiological 
manner.  In  different  individuals  whose  eyes  are  practicallv  nor- 
mal, the  minimum  power  of  adduction,  for  example,  may  be  quite 
small,  occasionally  only  half  the  average,  but  in  these  individuals 
we  find,  ordinarily,  that  the  minimum  power  of  the  opposing  group 
is  also  less  than  normal,,  and  often  in  a  corresponding  degree.  On 
the  other  hand,  there  are  individuals  who  have  a  minimum  power 
of  adduction  largely  in  excess  of  the  average,  and  in  these  we  are 
apt  to  find  a  correspondingly  large  amount  of  abductive  power. 
In  other  words,  it  is  certain  that  in  the  normal  condition,  we  may 
have  decided  variations  in  the  relative  strength  of  different  individ- 
uals, but  that  the  balance  between  the  opposing  groups  of  muscles 
remains,  a  in  general  way,  the  same.  A  pair  of  scales  will  balance 
whether  there  is  a  weight  of  the  grains  or  a  hundred  grams  on 
either  side. 

Test  of  Balance  With   Convergence. 

For  distance  heterophoria  is  as  frequent  as  orthophoria.  That 
is  not  the  case  when  accommodation  and  convergence  is  brought 
into  action. 

Test  of  Von  Graefe — dot  and  line.  When  the  individual  sees 
only  one  vertical  line  with  two  dots  in  its  course,  we  say  that  "mus- 
cle balance  exists  for  that  point,  whether  it  be  three,  four  or  five 
meter  angles  of  convergence.  This  condition  is  often  described  as 
orthophoria  at  the  near  point.  That  term,  however,  is  both  con- 
tradictory and  indefinite.  If  orthophoria  is  a  "tendency  of  the 
visual  lines  in  parallelism,  evidently  that  cannot  occur  in  conver- 
gence   If    the    two    dots    are    not   in    the   same    vertical  line, 

they  can  be  made  to  appear  so  by  placing  a  second  prism  at  right 
angles  to  the  first,  as  when  correcting  a  heterophoria.  The  position 
and  strength  of  the  second  prism  then  shows  the  kind  and  degree 
of  heterophoria,  which  exists  with  convergence  at  a  certain  num- 
ber of  meter  angles,  whatever  that  may  be. 

Stereoscopes.  The  Stereoscope  is  of  decided  assistance  in 
treating  certain  forms  of  muscular  difficulties. 


108  HAZEN'S  NEW  FINDINGS 

DIVISION  III. 

I'm      Relation     of    Accommodation    to    Convergence    and 
Relative  Accommodation. 

The  range  of  Accommodation — the  relative  accommodation — 
— the  plotting  of  relative  accommodation — how  the  range  of 
relative  accommodation  is  influenced  by  age  is  minutely  handled 
and  described. 

DIVISION  IV. 

Relation  of  Convergence  to  Accommodation — Relative 
Convergence. 

The  Clinical  Importance  of  the  Relations  of  Accommodation 
and  Convergence  will  be  met  at  every  turn  and  no  phase  of  our 
subject   is   worthy  of  more   careful   study. 

DIVISION  V. 

Relation  of  both  Accommodation  and  Convergence  to 
Torsion   or  True   Torsion   with   Convergence. 

The  relation  of  Torsion  is  elaborately  defined  and  the  measuring 
is  fully  described.  Torsion  is  one  of  the  three  factors  which  con- 
tribute to  comfortable  vision  at  the  near  point.  Relation  of  both 
Accommodation  and  Convergence  to  Torsion  with  Convergence. 
"Torsion  with  convergence  is  the  tipping  outward  of  the  upper 
ends  of  the  vertical  axes  (true  torsion)  which  accompanies  con- 
vergence. 

Appliances. — "It  is  necessary  to  distinguish  different  instru- 
ments for  measuring  the  tipping  of  the  vertical  axes."  Those 
which  measure  the  cyclophoria,  which  is  a  passive  condition — tor- 
tometers  which  measure  the  cycloduction.  "Most  of  the  Tor- 
tometers  are  also  Clinoscopes,  but  all  Clinoscopes  are  not  Tor- 
tometers." 

The  determination  of  the  plane  in  which  the  visual  axes  lie  is 
desirable.  Le  Contes'  method  is  the  simplest.  The  tipping  out- 
ward of  the  upper  end  of  the  vertical  axes  usually  increases  as  the 
plane  of  the  axes  of  vision  is  elevated  and  not  in  proportion  to  the 
amount  of  convergence.  It  is  relative.  The  object  of  torsion  is 
not  clearly  understood.  When  torsion  is  disturbed  artificially — 
the  effort  at  torsion,  which  the  eyes  make  to  fuse  these  lines,  gives 
a  sense  of  discomfort.  It  will  be  seen  that  torsion  must  be  taken 
into  account  together  with  accommodation  and  convergence. 
Muscle  Balance  is  (as  defined)  the  condition  in  which,  with  comfor- 
table  binocular   vision,    accommodation,    convergence,    and    torsion 


LUCIEN  HOWE,  M.  D.  109 

bear  their  normal  relations  to  each  other.  We  need  a  physiolog- 
ical standard,  with  which  to  compare  nervous  forms  of  muscle 
balance  ,or  unbalance  as  it  is  sometimes  called.  Muscle  Balance 
is   relative.      It  should    not  be  confused   with  orthophoria. 

Muscle  Balance   (Eukenesis). 

1st.  Relates  to  extrinsic  and  intrinsic  muscles. 

2nd.  Visual   lines   parallel  or  converging. 

3d.  Binocular  vision  must  exist. 

4th.  Comfort  is  essential. 

Relation  of  the  "General  Strength"  to  the  Physiological 
Action  of  the  Ocular  Muscles. 

The  power  of  the  eye  muscles  is  given  in  terms  of  prisms,  whereas 
the  condition  of  the  muscles  of  the  body  is  given  in  foot-pounds. 

"When  we  take  into  account  both  the  minimum  and  maximum 
power  of  different  groups  of  the  ocular  muscles — for  example, 
adduction  and  abduction — each  measured  by  different  methods, 
we  have  at  least  an  approximate  expression  of  the  strength  of  the 
ocular  muscles  in  that  individual."     "The  muscular  tone  does  not 

refer  to  the  strength  or  lifting    power it  is  the  ability  of  a 

muscle  or  a  group  of  muscles  to  perform  the  amount  of  work  nor- 
mally devolving  upon  them  without  the  development  of  fatigue 
.  .  .  .there  can  be  no  question  though,  but  that  this  normal  tone  of 
the  ocular  muscles  is  also  in  proportion  to  the  tone  of  the  muscles 
in  other  parts  of  the  body  of  that  individual.  ...  It  is  true  that 
we  often  find  invalids,  who  can  read  and  work  all  day  under  adverse 
circumstances."  Where  we  find  an  imbalance  or  fault  of  the  mus- 
cles, we  should  not  be  satisfied  with  local  means  only,  but  the 
strength  or  tone  of  the  muscles  of  the  body  should    be    improved  . 

HOWE,  VOL.  II. 

PART  I. 

Ocular  Muscle  Imbalance. 

The  three  primary  forces  in  the  act  of  comfortable  vision  have, 
each,  a  secondary  one — "resistance".  Balance  is  rare  as  perfect 
health,  but  it  does  exist.  Where  the  primary  and  secondary  fac- 
tors bear  their  normal  relations,  we  have  balance  or  eukenesis.  The 
range  of  variation  without  a  sensation  of  real  discomfort  has  been 
called,  "The  area  of  comfort."  Imbalance  is  the  condition  in  which 
accommodation,  convergence  and  torsion  do  not  bear  their  normal 
relations,  called  dyakinesis. 


lie  HAZEN'S  NEW    FINDINGS 

In  the  time  ol  Von  Graefe,  what  is  now  called  hcterophoria  was 
called  latent  convergence  and  divergence.  All  latent  abnormalities 
gradually  came  to  be  described  by  English  and  American  writers  as 
imbalance.  It  should  be  remembered  that  in  all  forms  of  eye 
strain — the  ultimate  cause  of  uncomfortable  svsmptoms  is  the  in- 
stinctive effort  to  obtain  and  to  maintain  perfect  vision,  and  also 
binocular  vision  when  that  is  possible.  Of  the  various  forms  of 
imbalance,  it  is  customary  to  speak  of  them  as  varieties  of  asthenopia. 
This  is  wrong  and  unfortunate — and  "we  shall  attempt  to  dispense, 
when  we  can.  with  the  term  asthenopia."  We  have  a  lack  in  our 
nomenclature,   which   includes  anomalies  of  accommodation. 

Intra-Ocular. 

According  to  our  modern  nomenclature  of  the  external  muscles, 
this  has  nothing  to  do  with  the  ciliary  muscle.  There  is  evident 
need  and  the  single  word,  heterocykinesis,  hereto  (varied)  cycle 
(as  in  cyclites)  Kinesis  (strength  or  tenacity)  but  we  have  the  English 
terms,  anomalies  of  accommodation,  spasm  and  paresis  (abnormal 
action  of  the  intra-ocular  muscles.) 

Extra-Ocular. 

Imbalance  of — We  know  these  as  latent  deviations  or  heterophoria 

Is  esophoria  due  to  excessive  contradiction  of  the  adductors  or 
associated  with  excessive  accommodation — that  is — is  it  active 
esophoria  an  actual  excessive  convergence,  or  is  it  the  tendency 
to  deviation,  dependent  on  some  abnormal  relaxitive  of  the  ab- 
ductors— that  is — is  it  passive  esophoria?  If  so,  it  would  be  a 
relative  excessive  convergence,  so,  in  a  similar  manner  with  the 
other  deviations,  and  of  this  proposition,  he  makes  eleven  groupings. 
Besides  these,  there  are  compound  forms  of  imbalance — mixed 
simple  imbalance,  and  an  associated  compound  imbalance.  Sim- 
ple Imbalance,  "is  one  in  which  there  is  an  abnormal  condition 
of  only  one  of  the  principal  forces  or  a  pair  of  forces,  which  enter 
into  the  act  of  normal  binocular  vision."  Compound  Imbalance, 
"is  one  in  which  there  is  an  abnormal  condition  of  two  or  more 
principal  forces  or  pairs  of  forces.  A  large  majority  of  all  cases 
of  imbalance  are  of  the  compound  forms."  Imbalance  should  not 
be  confused  with  its  results. 

"Eye  strain  is  a  result  of  ocular  imbalance.  A  person  may 
or  may  not  be  conscious  of  strain."  "Asthenopia  is  a  group  of 
symptoms — also  a  result  of  a  muscle  imbalance.  The  patient 
is   conscious  of  it,  often   to   a   painful   degree.      We  shall   deal  only 


LUCIEN  HOWE,   M.  D.  Ill 

with  those  few  symptoms,  which  all  practitioners  agree,  do  frequently 
accompany  imbalance.  These  may  be  called  the  cardinal  symp- 
toms. 

Blurring,  frequently  due  to  insufficient  focusing. 

Headache — varieties  almost  innumerable. 

Location  of — frontal,  vertex,  occiput,  extending  down  the  neck, 
even  to  the  back. 

Hyperemia  of  the  conjunctiva. 

Increased    Lachrymation. 

At  the  first  visit,  we  should  enter  only  a   provisional  diagnosis. 

SIMPLE  IMBALANCE  INVOLVING  ONLY  THE  INTRAOCULAR 

MUSCLES. 

DIVISION  I. 

"  Actual  Excessive  Accommodation." 

In  actual  excessive  accommodation,  he  unqualifiedly  answers 
affirmatively  that  it  is  desirable  to  make  a  really  exact  correction 
of  ametropia.  In  some  cases,  a  persistent  use  of  belladonna  for 
months — even  to  six. 

DIVISION  II. 

"Relative  Excessive  Accommodation,"  the  treatment  of  this 
simple  imbalance  is  by  correcting  the  ametropia. 

DIVISION  III. 

"Actual  Insufficient  Accommodation/"  find  the  cause  and 
treat  that  and  give  a  guarded  prognosis.  Bodily  exercise  is  recom- 
mended, but  ocular  exercise  is  not  mentioned. 

DIVISION  IV. 

Relative  Insufficient  Accommodation.  It  is  the  most 
important  simple  imbalance. 

The  insufficient  accommodation  is  dependent  upon,  or  relative 
to  the  resistance  offered  by  the  lens. 

The  range  of  accommodation  is  either  normal  or  its  action  is 
limited — the    positive    part    small — the    negative    large. 

A  sharp  line  of  distinction  cannot  always  be  drawn  between 
actual  and  relative  insufficient  accommodation — causes — Pres- 
byopia— Hypermetropia — Astigmatism — Treatment  is  obvious — 
If  discomfort  continues — rest  and  Dverism. 


112  HAZEN'S   Xi:W    FINDINGS 

DIVISION  V. 

I  nequal   Refraction   'Anisometropia)  Treatment-Correction. 
Simple   Imbalance   Involving  the  Extraocular  Muscles  Only. 
(Simple  heterophoria) 

EXTRA  OCULAR  MUSCLES. 

DIVISION  I. 

Latent  Deviations  Produced  by  the  Horizontal  Muscles. 

(Anomolies  of  Convergence.) 

SL  B-DIVISION  I. — -Active  esophoria  or  actual  excessive  conver- 
gence, excessive  action  of  adductors  rather  than  relaxation  of  ab- 
ductors. We  frequently  have,  in  normal  eyes,  a  tendency  of  the 
axes  to  converge  or  diverge,  when  the  individual  looks  into  the 
distance,  but  when  converging  and  accommodating,  we  have 
muscle  balance,  (eukinesis)  Symptoms  given  are  objective. 
Among  the  subjective  are  feelings  of  tension  and  panoramic  fa- 
tigue. 

Causes — -Anatomical,   Physiological,   Central. 

SUB-DIVISION  II. — Passive  Esophoria  [Relative  excessive 
convergence.)  Visual  axes  tend  to  turn  inward  from  lack  of  resis- 
tance of  abductors.  The  abductors  are  easily  fatigued.  Fre- 
quency is  not  as  great  as  the  active  form.  The  positive  relative 
convergence — large  and  often  irregular  at  different  points  and  also 
different  times.  Causes  may  be  anatomical — often  paralysis, 
paresis. 

SUB-DIVISION  III.— Active  Esophoria  {Relative  Insufficient 
Convergence.) 

This  is  a  rare  condition.  Cause — some  imperfect  action  of  the 
abductors.  Test — Von  Graefe's  dot  and  line  test.  Treatment — - 
Rest  is  not  here  indicated,  but  strengthening  convergence.  The 
problem  is  how  to  make  the  adductors  stronger  than  normal,  in 
order  to  balance  the  excessive  power  of  abduction.  That  is  not 
easy  to  accomplish.  A  gymnast  can  develop  the  muscles  of  the 
arm,  but  with  some  difficulty  and  only  to  a  limited  degree.  Some 
temporary  relief  from  the  discomfort  can  usually  be  obtained  by 
abductive  process,  but  when  continued  too  long  it  makes  matters 
worse.  In  this  form  of  exophoria,  advancement  is  warrantable. 
General  treatment — medication  and  hygiene. 


LUCIEN  HOWE,  M.  D.  113 

SUB-DIVISION    IV.— Passive    Kxophoria    {Actual,  Insufficient 

Convergence.) 

The  visual  axes  tend  to  diverge  because  of  insufficient  action  of 
the  adductors.  This  is  next  to  insufficient  accommodation  in 
frequency.  A  differential  diagnosis  from  the  active,  in  many  cases, 
is  impossible.  Objectively,  the  differential  diagnosis  can  be  made 
with  the  perimeter,  tropometer,  photograms.  Subjective — there 
are  abundant  and  varied  forms  of  eye-strain  —  the  cardinal 
symptoms  always  present.  Sometimes  we  have  an  imperfect 
knee-jerk.  Causes — anatomical — analogous  to  those  in  relative 
insufficient  accommodation — disturbance  of  the  nervous  system — 
over  correction  of  strabismus. 

Treatment — Exercise  of  the  ocular  muscles — Wall  and  wall 
exercise — Occasional  strong  prisms  for  a  distance — ditto  for  near- 
stereoscope — weak  prisms  for  constant  use  — decentering  lenses — 
gradual  and  frequent  strengthening  of  the  wearing  prisms. 

DIVISION  II. 

Latent  Deviations  Produced  by  the  oblique  Muscles. 

(Anomalies  of  Torsion)   Cyclophoria. 

SUB-DIVISION  I. — Excessive  Torsion.  The  frequency  seems 
to  be  rather  rare — perhaps  because  exact  measurements  of  it  are 
comparatively  few.  They  are  more  frequent  in  relation  to  astig- 
matism, and  more  important  than  is  usually  supposed.  Causes — 
Astigmatism.  Treatment. — Co.rection  of  ametropia.  As  to  exer- 
cise of  the  oblique  muscles,  thus  fai  the  results  obtained  have  been 
of  rather  doubtful  value. 

SUB-DIVISION  II.      Insufficient  Torsion. 

The  upper  end  of  the  vertical  axis  does  not  tend  to  turn  outward 
as  far  as  it  should  normally.  Treatment. — Same  as  division  I — 
with  modifications. 

DIVISION  III. 

SUB-DIVISION  I. — Latent  Deviations  Produced  by  the 
Vertical  Muscles  Hyperphoria  and   hypophoria. 

When  Hyperphoria  is  a  tendency  of  one  eye  to  turn  up  while  the 
other  fixes  the  distant  object.  Hypophoria  is  the  tendency  of  the 
other  to  turn  downward.  To  make  a  definite  diagnosis  between 
the  two  is  not  possible,  and  in  the  matter  of  treatment  is  of  slight 
importance.     The   vertical    symmetry    of    the    face   can    be   seen    in 


114  HAZEN'S   NEW    FINDINGS 

some  —  the  eyes  arc  not  on  the  same  horizontal  plane  and  it  is  often 
rectified  by  tipping  the  head.  We  do  not  know  whether  the  upward 
tendency  is  <>f  an  active  or  of  a  passive  nature.  Treatment. — 
Local  consists  in  use  of  prisms,  and  not  knowing  whether  the  ten- 
dency to  turn  up  is  dependent  on  undue  contraction  of  the  levators 
or  upon  relaxation  of  the  depressors — the  placing  of  prisms  is  em- 
pirical.     Operation  is  to  be  considered  only  as  a  last  resort. 

SUB-DIVISION    II.      Anophoria    and    Katophoria. 

Their  number  is  exceedingly  small  and  have  not  yet  been  studied 
with  the  care,  which  they  perhaps  deserve.  The  tendency  to  lower 
the  chin  and  raise  the  eyes;  the  deleterious  position  of  the  head  in 
its  effect  on  respiration,  (which  Stevens  gives)  he  thinks  "is  un- 
worthy of  serious  consideration."  he  considers  it  a  bad  habit  and 
shows  a  lack  of  proper  training.  He  suggests  a  prism,  with  base 
down,  over  each  eye.  Repetition  is  unnecessary  in  the  opposite 
position  of  Katophoria. 

COMPOUND  IMBALANCE. 

Anomalies   of   two   or   More   Groups   of   Muuscles. 
DIVISION  I. 

There  are  two  varieties — associated  and  disassociated.  "As  a 
disturbance  of  a  single  one  of  the  three  pairs  of  factors  is  apt  to 
also  disturb  the  relation  of  one  or  more  of  the  other  factors,  we  may, 
apparently,  have  as  man}'  different  forms  of  compound  imbalance 
as  there  are  permutations  of  six."  But.  disheartening  as  the  con- 
ditions may  be  at  first  glance,  the  treatment  problem  is  not  so  com- 
plicated, for,  "when  we  correct  the  principal  abnormal  element, 
the  others  associated,  tend  to  correct  themselves."  "Compound 
imbalance  is  not  a  disease,  but  only  the  name  of  two  or  more  abnor- 
mal muscular  conditions,  each  of  which,  is  by  itself  distinct  from 
the  other."  One  is  called  the  excesssive  or  spastic  type — excessive 
accommodation  and  an  esophoria  or  sometimes  an  excess  of  torsion. 
We  should  determine,  if  possible,  the  relative  importance  of  each 
element  in  the  compound  imbalance.  The  imbalance  of  the  intra- 
ocular muscles  is  usually  more  important  than  that  of  the  extra- 
ocular. "A  decided  imperfection  of  torsion  is  usually  of  more 
importance   than   an   imperfection  of  convergence." 


LUCIEN  HOWE,   M.  D.  115 

DIVISION  II. 

SUB-DIVISION  I.  Effects  of  the  Intraocular  Muscles 
on  the  Intraocular  Structures. 

Prolonged  effort  of  accommodation  produces  Cycletes,  Iritis, 
pathological  changes  in  Choroid,  in  Retina,  Macula,  Optic  nerve. 
Eye-strain  as  a  cause  of  Glaucoma  is  doubtful  but  it  is  claimed  by 
some,  it  causes  peripheral  opacities  in  the  lens. 

SUB-DIVISION   II. — Effects  of  the   Extraocular   Muscles 

ON    THE     GLOBE. 

No  one  can  study  the  aspect  without  being  convinced  that  the 
extra-ocular  muscles  do  affect  the  form  of  the  globe.  It  is  generally 
agreed  that  astigmatism  can  be  developed.  The  broad  tendons 
of  the  recti  and  especially  of  the  two  obliques  might  press  upon  the 
globe  to  impede  the  return  of  venous  blood  and  thus  increase  the 
ocular  tension. 

SUB-DIVISION  III.  Effects  of  the  Ocular  Muscles  on 
Neighboring   Structures. 

Hyperemia  of  the  Conjunctiva;  associated  with  it  a  feeling  of 
discomfort,  itching  or  distant  pain,  which  causes  the  person  to 
close  the  lid  and  rub  the  eyes;  increased  lachrymation;  corneal 
inflammation;   blepharitis,   associated   with   astigmatism. 

Headaches. — Our  ignorance  on  this  subject  is  almost  as  great 
as  it  was  a  half  century  ago,  depending  on  imperfect  nomenclature. 
The  locality  of  pain,  its  area,  and  whether  that  pain  is  accompanied 
by  tenderness.  "As  there  has  been  a  decided  looseness  in  using 
the  term  headache,  so  there  has  been  a  similar  laxity  in  using  the 
term  eye-strain  when  related  to  that  headache. "  We  wish  to  know- 
kind  and  degree  of  ametropia — imbalance."  It  is  divided  into  three 
groups. 

1st.  Headache,  the  result  of  contraction  of  accessory  muscles  of 
accommodation. 

2nd.     Those    which   are   directly   the   result   of  imbalance. 

3d.  Those  which  are  a  reflex  from  disorders  of  the  stomach  or 
other  parts  of  the  body. 

Torticollis  occur  in  some  forms  of  imperfect  action  of  the  ocular 
muscles.  Such  an  enforced  position  of  the  head,  maintained  for 
a  long  time,  results  in  the  condition  we  recognize  as  Torticollis  or 
Scoliosis. 


IK-  HAZEN'S   NEW    FINDINGS 

SI  B-DIVISION  IV.  Effects  of  the  Ocular  Muscles  ox 
thi  mm  k  parts  of  the  Body.     (Indirect  Effects  of  Imbalance.) 

They  arc  probably  produced  through  the  sympathetic  nervous 
system.  Their  importance  has  been  unduly  exaggerated — usually 
called,  "reflexes  of  eye  strain.''1 

"Donders,"  and  for  some  time  after  him,  no  one  suspected  that 
the  action  of  the  muscles  would  produce  much  inconvenience 
beyond  the  cardinal  symptoms,  which  were  then  called  asthenopia." 
"Gradually,  increasing  clinical  experience  has  modified  our  idea  of 
asthenopia."  Symptomatology  is  enlarged  beyond  the  cardinal 
systems,  to  "pain  extending  upon  the  neck  and  shoulders,"  nausea 
including  many  reflexes  of  a  neurotic  type,  dependent  upon  the 
the  use  of  the  eyes.  Many  of  these  symptoms  may  result  directly 
from  an  imperfect  action  of  the  ocular  muscles,  and  also  disturbances 
of  the  general  system,  acting  on  a  primary  cause,  may  affect  the 
ocular   muscles   and    are   called   asthenopia." 

Reflexes. — The  criterion  to  determine  whether  a  given  symptom 
is  the  result  of  muscle  imbalance — we  should  establish — (a)  "a 
relation  in  time — should  follow  the  imbalance  or  be  coincident 
with  it;"  (b)  "there  should  be  a  relation  in  degree;  ordinarily  the 
amount  of  imbalance  is  in  some  proportion  to  the  severity;  the 
severity  of  the  reflex  is  sometimes  entirely  out  of  proportion  to  the 
amount  of  imbalance;"  (c)  "the  partial  or  total  correction  of  the 
imbalance  should  produce  a  corresponding  effect  upon  the  reflexes;" 
(d)  "everything  which  may  be  considered  a  contributing  cause  in 
producing  reflexes  should  be  eliminated."  "The  frequency  of  such 
reflexes — especially  in  America,  is  noted  by  many."  Americans 
use  their  eyes  in  a  careless  manner.  The  hurry  and  mental  strain 
make  unusual  demands  on  the  nervous  system.  "Reflexes  are  due 
to  difficulties  of  digestion."  "Heat  and  dryness  of  the  atmos- 
phere in  our  homes  cause  Conjunctivitis  and  thus  give  rise  to 
symptoms  of  imbalance." 

SUB-DIVISION  V. — Effect  of  the  Ocular  Muscles  on  the 
Nervous  System. 

Headaches. — Indirectly  the  result  of  Imbalance. 

Sick  Headache  (migraine)  belongs  to  this  group.  The  litera- 
ture of  late  years  has  grown  large  in  which  the  remedy  has  been 
correction  of  the  refraction.  Fatigue,  easily  brought  on  by  use 
of  eyes.. 

Neurasthenia. — Imbalance  of  the  ocular  muscles,  with  the 
resulting  eye  strain,   is  one  of  the  causes  which  we  class  together 


LUCIEN  HOWE,  M.  D.  117 

under    that    one    name.     That    eye-strain    is    usually    a    prominent 
cause,    and   occasionally   the   only   cause,    is   an   extreme    view. 

Hysteria. — The  limbo  of  Neurotics,  and  the  unreliable  state- 
ments of  them  is  depicted. 

Chorea.  The  off-hand  statement,  frequently  made,  that  chorea 
is  always  or  even  usually  due  to  ocular  imbalance,  "is  not  supported 
by  fact."  There  are  a  few  cases  in  which  the  relation  between 
eye-strain  and  chorea  is,  apparently,  that  of  cause  and  effect.  To 
condemn  any  patient  to  glasses,  the  evidence  must  be  as  conclusive 
as  possible. 

Epilepsy. — The  term  means  nothing  exact.  "It  is  certain  that 
some  cases  show  a  distinct  relation  between  muscular  imbalance 
and  epilepsy."  In  a  small  number  of  cases,  the  attacks  are 
lessened  by  suitable  glasses. 

Other  Neurotic  Conditions. — The  literature  is  abundant.  The 
nervous  effect  on  the  mental  and  moral  conditions,  the  chain  of 
circumstances  is  far  from  complete. 

SUB-DIVISION  VI.  Effects  of  the  Ocular  Muscles  on 
Parts  of  the  Body  other  than  the  Nervous  System. 

On  the  teeth;  on  the  mucus  membrane  of  the  nose;  on  the  stomach. 
The  effect  of  extra  effort  at  focusing  or  movement  of  the  eyes,  as 
in  a  car,  swing,  or  with  some,  when  at  sea,  or  use  of  glasses  on  nor- 
mal or  abnormal  eyes,  affecting  the  stomach,  is  in  evidence.  It 
was  proved  by  a  case  of  gastric  fistula,  that  the  acerbity  of  the 
stomach  was  affected  by  certain  glasses.  On  certain  parts  of  the 
body;  the  heart,  the  liver,  the  kidneys,  it  is  doubtful  whether  the 
glasses,  which  were  thought  to  improve  these  condition,  did  more 
than  relieve  some  existing  eye-strain,  and  thus  directly  comforted 
the   patient. 

EXAGQERATED     OPINIONS     OF    THE     EFFECT    OF     EYE     STRAIN. 

If  we  admit  that  certain  reflexes  can  be  produced  by  imbalance' 
the  question  arises  why  all  reflexes  do  not  come  from  the  same 
cause.  Some  of  these  cases  of  nervous  reflexes  are  cured  by  the 
adjustment  of  glasses  or  by  certain  operations,  but  in  most  cases 
they  are  not.  Exaggerated  statements  have  been  made  in  late 
years  to  prove,  that  well  known  authors  have  been  sufferers  from 
eye-strain,  and  that  their  misanthropic  views,  indigestions  or  ill 
temper,  were  due  to  imperfection  of  the  ocular  muscles.  It  seems 
a  little  hasty,  to  say  the  least,  thus  to  jump  at  a  diagnosis  when  the 


US  HAZEN'S   NEW  FINDINGS 

patient  has  been  dead  for  many  years.  Such  literary  diversions 
arc  clever  and  popular  of  course,  but  let  us  not  call  them,  even 
semi-scientific  or  attempt   to  treat   them  seriously. 

DIVISION   III. 
Reflexes   to  the    Eye   from    Disturbances   ix   other   parts 

OK    THE     BODY. 

These  have  been  called  "Central  Asthenopia."  There  is  nothing 
to  show  that  any  of  these  reflexes  arc  "central"  in  the  sense  that 
they  arc  due  to  changes  in  the  brain. 

SI  15-DI  VISION  II.  Reflexes  to  yhe  eye.  Shown  as  Symp- 
toms of  Imbalance. 

Conjunctivitis. — We  must  not  allow  our  knowledge  of  refrac- 
tion or  of  muscle  imbalance  to  make  us  forget  that  these  symptoms 
may  be  the  result  of  a  simple  conjunctivitis  and  is  to  be  treated  as 
Mich.  Ocular  headaches  are  of  entirely  reflex  character.  These 
are  not  dependent  upon  muscle  imbalance.  Ocular  headaches 
cause  disturbances  of  the  stomach,  as  for  instance,  a  distinct  dis- 
comfort just  above  the  eyes,  when  cold  is  taken  into  the  stomach. 
In  some  cases  the  gastric  condition  produces,  not  simply  reflex 
symptoms,   but  also   a   distinct  imbalance. 

From  disturbance  of  the  intestinal  canal. 

From  imperfect  nutrition  and  from  toxaemias. 

In   anaemic  or  chlorotic   cases. 

Headaches  from  toxaemias. 

When  a  patient  complains  of  ocular  headache,  which  glasses 
fail  to  relieve  promptly,  it  becomes  the  duty  to  have  a  reliable 
examination  made  of  the  blood  or  of  the  contents  of  the  stomach, 
or  have  the  urine  tested,  and  ,if  necessary,  an  examination  made 
of  the  blood  pressure. 

Reflex  to  the  eye  from  the  nose. 

Reflex  to  the  eye  from  the  ear. 

Symptoms  of  Imbalance  after  injury. 

Non-Traumatic  Nerve  Lesions. 

Splanchnoptosis. 

SUB-DIVISION  II.  Reflexes  to  the  Eye  from  Imperfect 
Nutrition,  Intoxication,  etc  Shown  as  Actual  Muscle 
Imbalance. 

Distinct  Imbalance  is  produced  by  imperfect  nutrition,  intoxi- 
cation or  by  some  disturbance  of  the  function  in  another  part  of 
the  bodv. 


LUCIEN  HOWE,   M.  D.  119 

DIVISION  IV. 
SUB-DIVISION   I.     Treatment  of  Compound  Imbalance. 

A.  Correct  any  Intra  Ocular  Imbalance. 

B.  The  correction  of  any  imbalance  of  the  Extra  Ocular  Muscles 
by  prisms  or  by  decentered  lenses,  affords,  at  least,  temporary 
relief  by  placing  them  in  such  a  position  as  to  favor  the  affected 
muscle.  Usually,  it  is  preferable  to  turn  the  prism  in  the  opposite 
direction  if  the  best  ultimate  results  are  desired. 

C.  ''In  Associated  Compound  Imbalance,  if  \vc  correct  the 
function  or  feature  of  the  imbalance,  then  the  muscle  balance  oi 
at  least  improvement  follows." 

D.  "In  some  cases  of  associated  and  in  nearly  all  cases  of  dis- 
associated compound  imbalance  it  is  necessary  to  deal  with  each 
compound  function  or  feature  of  the  imbalance  according  to  the 
principles  of  simple  imbalance." 

SUD-DIVISIOX  II.  Recognition  and  Treatment  of  Gen- 
eral Causes  of  Imbalance. 

Anaemia  and  Tests  of  the  Blood. 

Auto-intoxications  and  tests  of  the  Urine. 

Auto-intoxications — especially  with  sick-headache  and  tests  of 
the  stomach  contents. 

Headaches  and  other  symptoms  of  Imbalance  and  Tests  of  the 
Blood  Pressure. 

SUB-DIVISION   III.     Simple  Forms  of  Gymnastic  Exercise. 

(Condition  of  the  muscular  system  as  a  whole  and  Ocular  Muscles.) 

SUB-DIVISION  IV.  The  Optical  Treatment  of  Muscle 
Imbalance   by  the   Optician   or   by   the   Ophthalmologist. 

PART  II. 

ACTUAL   DEVIATIONS   DUE   TO   LESIONS   OF   THE   EXTRA 
OCULAR    MUSCLES    OR    IN    THE    GLOBE. 

Definitions. 

"When  the  visual  axis  of  one  eye  fixes  a  certain  point,  the  fellow 
eye  is  directed  to  some  other  point.  This  describes  an  Actual 
and  Manifest  deviation  as  distinguished  from  forms  of  heterophoria, 
in  which  there  exists  only  the  tendency  to  deviation.  These  actual 
deviations,  usually  called  "Strabismus"  or  "squint"  arc  now  termed 
"Heterotropia.".  This  we  use  as  a  synonym  for  "deviation. 
Deviations  are  paralytic  or  non-paralytic. 


120  HAZEN'S   NEW   FINDINGS 

SYMPTOMS  AND  DIAGNOSES. 

DIVISION  I. 

Deviations  and  their  Measurement. 

The  Linear  Strabometer. 

The  Strabometer  of  the  author.      (Howe) 

Corneal  Reflexes.     Maddox  Rod. 

With  Flattened  Perimeter. 

The  Tripometer. 

The  Production  of  Diplopia. 

Photographs. 

DIVISION  II 

Symptoms  of  Non-Paralytic  or  Active  Deviations. 

One  in  which  there  is  no  evidence  of  a  subnormal  action  of  the 
muscle  or  group  of  muscles,  away  from  which  the  visual  axis  deviates 
.  .  .  .due  more  to  excessive  action  of  one  muscle  or  group  of  muscles 
than  to  insufficient  action  of  the  opponents."  The  degree  varies 
greatly.  It  may  be  primary  or  secondary.  It  may  be  permanent 
or    variable. 

DIVISION  III. 

ARRANGEMENT  OF  DATA  AND  PLAN  OF  STUDY.      SINGLE 
LESION    WHICH    PRODUCE    ACTUAL    NON- 
PARALYTIC DEVIATIONS. 

(Simple  Heterophoria.) 

DIVISION  I. 

Deviations  Due  to  Abnormal  Muscles. 

Muscular  heterotropia  is  an  abnormal  condition  of  the  Extra 
Ocular  muscles,  which  produce  deviations  of  the  globe,  but  in  the 
majority  of  cases,  the  original  cause  of  the  deviation  is  not  an 
excessive  or  insufficient  action  of  the  muscles,  but  is  owing  to  some 
imperfection  of  the  globe.     "Typical  examples  are  rare." 

Symptoms. — These  are  neither  numerous  nor  reliable.  By 
exclusions'  process  we  may  say,  there  is  an  hypertrophy  or  shortening 
of  one  group  of  muscles  or  atrophy  or  lengthening  of  the  opposing 
group.  Often  there  is  little  or  no  ametropia.  To  assume  that 
these  cases  are  from  a  defect  of  the  fusion  faculty  "is  simply  begging 
the  question."  There  are  certain  facts  wrhich  indicate  that  these 
deviations  are  caused  by  anatomical  variations,  from  the  normal 
type. 


LUCIEN   HOWE,   M.  D.  121 

Treatment. — Determine  whether  active  or  passive.  Then  if 
good  vision  is  present,  muscle  exercise  can  be  practiced  to  advantage. 
When  such  exerciseis  not  practicable,  operation  is  the  only  treatment 
available. 

DIVISION  II. 

Deviations  Due  to  Ametropia. 

SUB-DIVISION  I.     Hypermetropic  Esotropia. 
(Strabismus  or  Squint.) 

As  Donders  taught,  and  others  subsequently  have  proved  beyond 
question,  ametropia  is  a  cause  of  deviations  inward.  By  separating 
this  group  from  others,  the  pathological  conditions  can  be  well 
defined  and  treatment  better  understood. 

SUB-DIVISION   II.     Myopia  Exotropia. 

Resulting  from  a  myopia,  with  or  without  Astigmation. 
Pure  types,  rare.     Usually  secondary  changes  in  the  retina. 

DIVISION  III. 

Deviations  Due  to  Imperfections  of  the   Retina. 
Defect  of  the   Fusion   Faculty-Amblyopia  in  the   Retina   or 

in  the   Brain. 

DIVISION  IV. 

Deviations  due  to  Imperfections  of  the    Refractive    Media. 

Opacity  of  Cornea. 

Superficial  Cicatrix  from  Ulceration,  etc. 

DIVISION  V. 

Some    Secondary    Causes,    which    may    contribute    with    any 
Single  Lesion  to  produce  a  Deviation. 

Occupation,  Irritation,  Anisometropia,  Heredity. 

DEVIATIONS  DUE  TO  TWO  OR  MORE  LESIONS. 

(Compound  Heterotropia.) 

Muscular  Lesions.  Abnormal  condition  of  the  Extra-ocular, 
is  in  many  cases  the  underlying  cause.  ..  .Ametropia,  Imperfect 
Retinal  Perfection 

Treatment.  For  the  non-operative  it  is  to  correct  the  ametropia, 
improve  the  amblyopia,  and  strengthen  the  weaker  muscles,  but 
to  follow  this  as  a  routine  plan,  we  found  neither  scientific  nor 
satisfactory. 


122  HAZEN'S  NEW  FINDINGS 

PART  III. 

ACTUAL    DEVIATIONS   DUE    TO    LESIONS,    IN   THE   BRAIN 
OR  IN  THE  NERVES. 

Paralytic. — Ophthalmoplegia    (Hutchinson). 

Ophthalmoplegia  interna-paralysis  of  all  the  nerve  fibers,  sup- 
plying the  tissues  on  the  interior  of  the  globe,  while  the  term  Oph- 
thalmoplegia externa  was  used  to  designate  those  cases  in  which 
"all  or  most  of  the  muscles  which  move  the  globe"  were  affected. 

DIVISION  I. 

Symptoms  and   Diagnosis. 
Summary.      (Compare  with  Landolt.) 

DIVISION  II. 

Aids  to   Diagnosis. 

DIVISION  III. 

Differential     Diagnosis     is     between     the     Xon-Paralytic, 
(active)  and  the  paralytic  (passive)  Deviations. 

In  view  of  an  operation,  it  is  necessary  to  know  how  to  decide, 
whether  a   tenotomy  or  an   advancement. 

PARALYSIS  OF  THE  THIRD  NERVE. 

I.  Cerebal  Lesions. 

II.  Basilar  Paralysis. 

III.  Orbital  Paralysis. 

IV.  Peripheral  Paralysis. 
Peripheral  Paralysis  of  the  Third  Nerve. 
Paralysis  of  the  Fourth  Nerve. 
Paralysis  of  the  Sixth  Nerve. 
Paralysis  of  branches  of  the  Sympathetic. 
Causes  of  Ocular  Paralysis. 
Prognosis. 

Treatment. 


LUCIEN   HOWE,   M.   D.  123 

PART  IV. 

ATYPICAL   MOVEMENTS    OF   THE   EYE.    INFLAMMATIONS 
AND    INJURIES    OF    THE    MUSCLES. 

Atypical  Movements. 

DIVISION  I. 

1st.     Definition. — Movements  which  do  not  seem  to  be  related, 
in  any  way,  to  the  deviations  we  have  considered. 
2nd.     Voluntary  Movements  of  one  eye. 
3d.      Refraction  Movements  of  the  Eyes. 
4th.     Atypical  Associated  Muscle  Action. 
5th.      Hysterical  Deviations. 

DIVISION  II. 

Inflammations   and   Injuries   of  the   Muscles. 

Rheumatism,    Myosites,    Progressive    Atrophy,    Injuries    of    the 
Extra-Ocular  Muscles. 

PART  V. 
Operations  on  the  Muscles. 


PART   II. 
MONOGRAPH 

BY 

E.  H.  HAZEN,  M.  D. 


ASTHENOPIA  AND  EYE  STRAIN. 
Philology. 

The  Philology  of  a  subject  often  gives  the  best  history 
of  its  development  and  leads  toward  an  understanding 
of  its  nature. 

The  gradual  change  in  the  definition  of  the  word 
asthenopia  from  an  "affection  of  the  retina,"  as  it  was 
regarded  when  Donders  came  upon  the  stage,  and  his 
transferring  the  mystery  of  the  phenomena  to  the  function 
of  accommodation  as  a  cause,  is  an  epoch  in  the  science. 
From  his  time  until  near  the  present,  the  word  designated 
a  disease  and  it  was  placed  at  the  heads  of  chapters  and 
then  belonged  to  the  glossary  of  disease,  (as  by  Stellwag 
and  Noyes)  but  it  did  not  stay  there  long  for  the  word 
as  it  appeared  in  the  later  writings  of  the  time,  was 
used,  as  it  now  is,  to  designate  a  symptom.  The  most 
modern  writers  now  use  it  thus  and  some  do  not  dignify 
it  with  a  definition,  but  use  it  as  they  do  the  words 
"pain  and  discomfort," 

Of  late  years,  the  term  "eye-strain"has  arisen  and  has 
become  more  general  in  use  and  it  now,  not  only,  conveys 
the  idea  of  pain  or  discomfort  but  points  to  the  under- 
lying cause,  and  this  substitution  of  the  description  of 
the  cause  of  the  trouble  complained  of,  has  come  into 
quick  use  because  of  its  less  scientific  ring  than  that  of 
asthenopia.  Many  writers  use  the  terms  synonymously. 
The  definition  of  these  words  by  different  authors,  as 
they  have  come  down  to  the  profession,  will  show  the 
insight  its  members  had  into  this  most  prominent  affection 
of  all  eve  troubles. 


ll>  HAZEN'S  NEW  FINDINGS 

In  addition  to  what  we  have  already  laid  out  in  the 
synopsis  of  asthenopia,  we  add  the  following: 

Howard  (1850)  defines  it  as  amblyopia  or  weakness  of 
sight.  He  considers  it  as  arising  from  constitutional 
causes. 

Mackenzie,  (1855),  Asthenopia  is  "an  incapability  of 
sustaining  the  adjustment  to  near  objects." 

Jones,  (1863),  Asthenopia  is  "weakness  of  sight;" 
"debility  of  apparatus  of  adjustment  to   near  objects." 

Macnamara,  (1876),  A  feebleness  of  vision  from  defec- 
tive or  irregular  muscular  action;  the  internal  rectus 
being  at  fault  in  motor  asthenopia,  and  ciliary  muscle 
in  the  accommodative  form  of  disease. 

Schell,  (1881),  Asthenopia  is  a  word  used  to  express 
forms  of  pain.  There  is  Muscular  Asthenopia,  in  Myopia 
from  strain  of  internal  recti  during  forced  convergence. 

Mettendorf,  (1881),  "After  using  the  eyes  for  near 
objects  for  some  time  ,a  weakness  of  one  or  both  internal 
recti  muscles  becomes  manifest.  The  weakness  may  be 
caused  by  efforts  of  convergence,  especially  from  change 
of  shape  of  the  eyeball,  or  it  may  result  from  severe  con- 
stitutional  disease." 

Ranney.  Nervous  Diseases.  (1888),  "Asthenopia  is 
that  condition  of  visual  apparatus  which  entails  suffering 
in  consequence  of  defective  equilibrium  in  the  muscular 
power  exerted  upon  that  organ,  when  a  fixed  position  of 
the  eye  is  maintained  for  any  length  of  time.  The  patient 
may  or  may  not  have  refractive  error." 

Ranney,  in  Eye  Strain — (1897),  In  this  work  he  does 
not  define  the  word. 

Swanzy,  (1897),  uses  the  word  in  a  general  sense — 
hurting  on  use  of  eyes  at  near  work.  Conjunctival, 
Insufficiency,  Nervous,  Muscular — Muscular  is  caused 
by  insufficiency  and  is  a  disturbance  of  the  equilibrium. 


HAZEN'S   NEW   FINDINGS  129 

De  Schweinitz,  (1892),  uses  the  word  without  special 
definition.  He  recognizes  Accommodative,  Muscular  and 
Neurasthenic  Asthenopia. 

Fuchs,  (1899),  recognizes  Accommodative,  Muscular 
and  Nervosa,  associated  with  near  work,  and  "panorama" 
asthenopia"  distant. 

Jackson,  (1900),  does  not  define  asthenopia  or  eye 
strain.  He  uses  them  synonymously  in  describing  symp- 
toms of  disordered  function  and  names  eye  strain  "as 
cause  of  many  diseases  and  confines  the  term  of  asthenopia 
to  the  pain  and  discomfort  of  the  eye  in  functioning. 

Fox,  (1904),  defines  asthenopia  as  "a  technical  name 
for  a  group  of  symptoms  resulting  from  eye  strain  due 
to  errors  of  refraction  or  fatigue  of  the  ocular  muscles." 

Berry,  (1905),  "Asthenopia  is  a  name  generally  given 
to  the  inflammatory  pain  associated  with  the  use  of  the 
eyes,  which  literally  means  a  want  of  power  in  the  eyes 
to  perform  their  functions." 

Ball,  (1904),  uses  the  word  asthenopia  as  a  symptom 
and  recognizes  accommodative,  Muscular  and  Neuras- 
thenic asthenopia. 

Eye  Strain.  The  use  of  the  term  "Eye  Strain"  is 
becoming  almost  universal  in  describing  affections  of  the 
eyes,  resulting  from  the  functional  use  of  these  organs. 
Some  of  the  former  authors,  however,  ignore  the  word 
and  use  asthenopia  instead,  and  some  use  them  inter- 
changeably. 

The  term,  "Eye  Strain,"  is  not  in  the  vocabulary  of 
Mackenzie,  Donders,  Howard,  Stellwag,  Wells,  Metten- 
dorf,  Schmidt,  Rumpler,  Macnamara,  Williams  of  Boston, 
Schell,  Fuchs,  Landolt,  Roosa,  Berry,  Ball,  de  Schweintz, 
nor  in  Billings'  dictionary. 

Gould  says,  "Eye  strain  is  the  name  given  to  any 
unphysiologic,  i.  e.,  pathologic  ocular  action  or  function 
which  is  wearing,  excessive  or  unnatural.  Popular 
Science  Monthly.     Dec.  1905. 


130  HAZEN'S   NEW   FINDINGS 

It  seems  at  present  that  t he  consensus  of  opinion  is  to 
regard  Eye  strain  as  expressive  of  the  trouble  of  the  eye 
in  functioning,  and  Asthenopia  as  the  principal  symptom 
of  pain  and  discomfort  connected  therewith. 

If  the  word  Asthenopia  is  held  closely  to  mean  the 
symptom  of  pain  or  discomfort  arising  from  the  eye, 
wheresoever  that  symptom  is  located,  we  have  a  very 
expressive  and  satisfactory  word. 

In  the  synopsis  which  I  have  given  on  this  subject, 
and  which  I  have  attempted  to  elucidate,  by  quoting 
freely  from  well  known  authors,  it  can  easily  be  detected 
that  authors  are  drifting  away  from  the  former  method 
of    studying    the    phenomena    we    now    call    Eye    Strain. 

They  have,  in  these  latter  days,  gradually  dropped  the 
descriptions  of  the  numerous  symptoms  connected 
therewith,  as  we  find  them  in  Donders  and  Noyes  and 
seek  other  methods  as  a  guide  to  ferret  out  the  mischief 
these  disorders  present. 

Since  Donder's  doctrine  that  the  physiological  cause  of 
asthenopia  existed  in  the  ametropic  condition  of  the  accom- 
modative apparatus,  and  especially  since  the  admission 
that  the  motor  apparatus  of  the  extrinsic  muscles  par- 
ticipates, and  since  it  is  conceded  by  some  that  they 
may  wholly  be  the  seat  of  the  trouble,  there  has  been 
built  an  extensive  theory  of  a  mechanical  nature  rather 
than  a  physical  condition  to  account  for  the  departure 
of  this  apparatus  from  the  normal. 

In  other  words,  the  attention  is  directed  to  the  position, 
direction  of  movement,  results  of  action,  deviations 
from  standards  of  position  and  action,  and  the  measure- 
ments of  all  these,  instead  of  a  study  of  the  causes  that 
have  brought  these  conditions  about.  They  seek  to 
remedy  these  wayward  "end  organs"  by  adjusting  them 
to  their  ideals,  rather  than  by  the  consideration  of  the 
psychical    forces    that    control    and    bring    into    creation 


HAZEN'S   NEW    FINDINGS  131 

the  sense  of  sight  and  keep  it  in  repair  for  the  best  ser- 
vice. 

The  method  of  study,  so  long  practiced  in  general 
medicine  of  noting  symptoms  and  grouping  these  to 
direct  the  course  of  investigation  is  being  dropped  and 
the  foot  rule,  the  scale,  the  motion  indicator  and  the 
balance  are  used  to  explain.  These  modern  methods 
which  call  in  the  miscroscope  and  the  test  tube  in  many 
diseases,  do  not  seem  applicable  to  the  diseases  which 
we  are  now  considering,  for  these  belong  to  the  nervous 
system  and  their  connection  is  with  the  brain;  they 
produce  phenomena  of  a  disordered  action  and  a  mental 
outlook  that  is  difficult  to  understand,  and  is  beyond 
measurement  and  borders  on  mystery,  and  though  it 
takes  such  a  hold  on  life  and  is  so  intangible  in  character, 
is  yet  exceedingly  veritable,  amd  afflicts  a  large  per- 
centage of  the  intelligent  part  of  the  community. 

BALANCE  AND  EQUILIBRIUM. 

We  see  by  reference  to  our  coterie  of  Authors,  that 
up  to  the  time  of  1890  when  Dr.  Xoyes  wrote  his  last 
large  work,  there  had  not  been  anything  said  about 
imbalances. 

About  this  time,  Dr.  Stevens  gave  to  the  profession 
his  nomenclature  with  its  system  of  measurements  of 
the  relation  of  the  two  balls  to  each  other,  and  his  in- 
struments of  precision.  He  also  made  more  emphatic 
the  importance  of  the  strength  and  action  than  had  been 
made  before  his  time  and  that  of  Dr.  Xoyes. 

Ranney,  (1888),  who  was  a  student  of  Dr.  Stevens, 
used  the  word  balance  in  a  foot  note  in  defending  their 
doctrine  of  "latent  insufficienc^',,  and  he  uses  the  word 
equilibrium  in  a  general  sense  but  not  in  so  specific  a 
sense  as  it  has  been  used  of  late. 


132  HAZEN'S  NEW   FINDINGS 

From  about  this  time  for  a  decade.  Ophthalmology 
has  been  re-written  on  the  basis  of  what  Stevens  gave  to 
the  subject. 

The  direction  thus  taken  was  that  of  considering  the 
cause  of  trouble  in  this  organ  to  be  in  the  findings  there- — 
mal-adjustmcnt,  misfit  muscles  and  corkscrew  motions 
of  the  balls. 

It  is  perfectly  logical  to  consider  symptoms  as  a  minor 
and  subordinate  matter  if  this  way  of  looking  at  it  is 
the  true  one;  symptoms  will  vanish  when  the  ideal 
equilibrium  is  restored  and  balance  is  brought  about. 
But  in  this  conception  of  the  situation  we  are  losing 
the   guide  of   symptoms   to   a   physiological   regulator. 

A  number  of  books  have  appeared  which  deal  with  the 
subject  in  this  way.  Since  muscular  disorders  have  been 
acknowledged  to  be  a  cause  of  asthenopia,  a  system  of 
interrelation  of  the  intrinsic  and  extrinsic  muscles  has  been 
well  worked  and  the  principal  physiological  phenomena 
found  in  this  conception  is,  that  the  abnormal  imbalance 
of  the  extrinsic  muscle  has,  for  its  explanation,  the 
abnormality  of  the  intrinsic  muscles.  This  gets  no 
farther  than  Donders. 

At  the  risk  of  being  considered  "prolix,"  let  us  examine 
this  doctrine  of  "balance",  "equilibrium"  and  some 
other  associated  ideas  that  have  relation  to  the  motor 
apparatus  and  its  anomalies. 

The  work  of  Dr.  Stevens,  which  gave  us  a  system  with 
a  definite  basis  on  which  to  found  a  proper  examination 
of  the  muscles  of  the  eyes  and  their  relations  to  each 
other,  was  a  master  stroke  on  this  subject. 

Before  that,  the  study  was  prosecuted  at  the  near  point, 
entangled  with  the  ever  varying  relation  of  accommoda- 
tion and  convergence. 

Examination  at  a  distance  of  20  feet  gives  the  best 
point  at  which  to  obtain  rest  of  the  organ  in  its  functional 
action.     At  this  point  from  which,  practically,  the  rays 


HAZEN'S  NEW  FINDINGS  133 

of  light  come  parallel,  it  is  seen  that  the  eye  must  be 
examined  to  ascertain  whether  there  are  departures 
from  this  ideal  point  of  rest. 

The  eyes  do  not  always  remain  at  rest,  for  it  is  difficult 
"for  individuals  to  permit  the  eye  muscles  to  become 
entirely  passive."  "Notwithstanding  the  imperfection 
of  the  theory,  we  possess  no  method  of  investigation 
better  than  producing  diplopia  of  the  image  at  this 
distance."  "No  just  appreciation  of  the  muscular 
balance  can  be  arrived  at,  while  the  accommodation  is 
considerably  exercised  or  while  convergence  is  required." 
(Stevens). 

The  new  conception  of  "balance  or  equilibrium"  took 
hold  of  the  profession  in  the  decade  of  the  '80's  and 
writers  on  Ophthalmology  hurried  to  re-write  their  papers 
and  books  on  this  new  basis. 

Dr.  Stevens  says,  "equilibrium  should  signify  a  con- 
dition in  which  all  the  muscles  of  the  eyes  are  so  pro- 
portioned and  adjusted  in  respect  to  their  dynamic 
conditions  that,  with  the  least  expenditure  of  nervous 
energy,  when  the  gaze  is  directed  to  an  object  in  the 
median  plane  at  the  level  of  the  eye  and  at  infinite  dis- 
tance, while  the  head  is  in  the  primary  position,  the 
visual  lines  should  be  parallel  and  in  the  same  horizontal 
plane." 

He  does  not  use  the  term  "balance"  in  his  "Motor 
Muscles"  but  in  his  contribution  to  System,  the  title  of 
which  is,  "The  Principles  of  and  Methods  for  the  estima- 
tion of  the  Balance  of  the  Extra-ocular  Muscles."  In  this 
article  he  says,  "the  best  muscular  equilibrium,  that  is 
the  condition  in  which  parallelism  of  the  visual  lines  is 
maintained  with  the  minimum  of  nervous  effort,  the  con- 
dition is  known  as  Orthophoria.     (\ol.  II.) 

Landolt,  in  "Refraction  and  Accommodation"  does 
not  use  terms  balance  or  equilibrium,  but  in  System  ( 1900) 
says,   "The   position  of  equilibrium   is   used   to   designate 


134  HAZENS    NKW    FINDINGS 

the  direction  taken  by  the  eyes  when  in  a  state  of  minimum 
innervation  or  of  absolute  repose.'"  Nothing  is  more 
difficult  than  to  find  this  position."  On  further  at- 
tempting to  get  his  idea  of  equilibrium,  it  is  found  that 
he  defines  it  to  mean  the  point  of  rest  in  any  (even) 
heterophoric  conditions,  for  he  says,  "  the  Maddox  rod 
is  a  good  method  of  determining  the  position  of  equili- 
brium or  latent  deviation  of  the  eyes,"  and  further  on 
he  says,  "that  in  profound  narcosis  or  death  the  eyes  are 
turned   outward." 

Dr.  Howe  does  not  use  the  word  equilibrium  in  Vol. 
I.  but  defines  Muscular  balance  as  "the  condition  in 
which,  with  comfortable  binocular  vision,  accommoda- 
tion, convergence  and  torsion  bear  their  normal  rela- 
tions to  each  other.  He  sets  his  definition  of  balance 
against  Dr.  Stevens'  Orthophoria  of  Equilibrium  thus: — 

Orthophoria.  Muscle    Balance.  (Eukenesis.) 

1.  Relates  to  extrinsic  muscles        1.      Relates   to  extrinsic  and  in- 
only,  trinsic  muscles. 

2.  Visual    lines    tend    to    paral-       2.      Visual  lines  parallel  or  con- 

lelism.  verging. 

3.  Binocular     vision      may     or       3.      Binocular  vision  must  exist, 
may  not  exist. 

-1.      Comfort    may    or    may    not       4.      Comfort  is  essential, 
exist. 

Other  differences  might  be  named  in  the  definitions 
of  the  conditions  in  which  the  term  Balance  is  used  by 
one,  and  Equilibrium  by  the  other. 


Stevens.  How 


e. 


1.  There  is  a  definite  point  of  1.  The  ever  shifting  condition 
departure  for  a  standard.  requires      a      standard      for 

each  of   his   numerous   sub- 
divisions. 

2.  There  is  a  common  standard  2.  The  normal  can  never  be 
for  all  departures  of  the  found  for  it  is  in  action  ib 
normal.  manv  directions. 


HAZEN'S   NEW   FINDINGS  135 

If  the  point  of  rest  and  parallelism  of  Stevens  is  not 
adhered  to  as  a  standard,  we  have  none  from  which  the 
abnormal  is  a  departure. 

The  Strength  of  the  Muscles. 

Another  consideration  in  the  study  of  the  subject  of 
eye  strain  is  that  of  the  strength  of  the  extrinsic  muscles 
(Eukenesis)  and  their  facility  of  action.  Donders  and 
Von  Graefe  had  no  idea  of  their  place  in  the  problem  of 
asthenopia. 

The  turning  of  the  visual  gaze  from  one  point  to  another 
and  the  fixation,  adjustment  or  projection  of  an  eye 
upon  an  object  are  of  course  muscular  efforts.  Accom- 
modation is  a  muscular  act  of  the  ciliary  muscle  and  con- 
vergence is  an  extra  effort  of  the  adductors. 

They  recognized  weakness  of  these  muscles,  but  at- 
tributed the  manifestations  of  it  to  errors  of  refraction, 
which  gave  the  muscles  extra  labor,  from  which  fatigue 
and  symptoms  of  pain  arose. 

When  there  was  no  ametropia  the  asthenopia  was 
termed,  by  Donders,  "false  asthenopia,"  and  rather  than 
attribute  it  to  affections  of  the  muscles  themselves,  a 
cause   was   sought   in   constitutional   disturbances. 

When  it  was  found  that  asthenopia  occurred  in  cases 
of  emmetropia  or  that  it  continued  when  they  had  been 
made  emmetropic  by  glasses,  they  still  relegated  the  pa- 
tient to  rest,  constitutional  treatment  or  change  of  occu- 
pation which  gave  them  less  activity  in  the  use  of  their 

eyes. 

As  late  as  1000  when,  through  the  writings  of  Xoyes,  the 
profession  had  come  to  believe  in  Muscular  Asthenopia 
and  to  recognize,  in  theory  at  least,  that  when  there  was 
weakness  of  the  extrinsic  muscles,  they  should  be  treated 
by  discipline  to  strengthen  them— the  directions  for 
doing  this  were  still  of  the  most  vague  and  unsystematic 
sort. 


136  HAZEN'S  NEW  FINDINGS 

Dr.  Noyes  developed  a  practical  method  for  disci- 
plining these  muscles,  and  showed  much  patience  in  this 
particular  necessity  as  he  found  it. 

Landolt  saw  the  weakness  of  muscles  and  compared 
it  to  the  condition  of  an  equestrian,  out  of  practice  and 
liable  to  he  thrown  from  his  horse  and  recommended 
discipline  of  leg  convergence,  that  he  might  be  able  to 
stick  to  his  animal. 

But  for  the  weak  convergence  of  the  recti,  he  merely 
suggested  discipline  without  exercising  his  usual  acumen 
in  inventing  apparatus,  as  he  did  for  diagnosing. 

All  along,  for  a  couple  of  decades,  the  opinions  of  writers, 
pro  and  con,  in  regard  to  the  question,  whether  there 
was  such  a  thing  as  Muscular  Asthenopia,  and  whether 
the  discipline  of  the  muscles  was  of  any  avail,  were  freely 
given. 

"Insufficiency"1  was  regarded  a  weakness,  yet  remedies 
for  weakness  were  not  used  to  strengthen.  Dr.  Dyer, 
as  we  have  seen,  was  the  first  to  institute  measures  of 
relief  according  to  the  laws  of  physical  culture.  His 
system  was  empirically  applied  and  consisted  in  dis- 
ciplining the  ciliary  as  well  as  the  recti  in  convergence, 
and  to  so  change  the  relation  between  the  two  that  there 
was  a  new  environment,  or  a  new  order  of  things — he 
did  not  know  what  or  howr — but  discipline  was  insti- 
tuted for  the  muscles,  for  the  first  time  in  Ophthalmic 
history. 

This  system  was  taken  up  throughout  the  land  and 
much  was  said  of  it.  A  few  cases  were  restored,  after 
months  of  severe  trial  and  watching,  and  infinite  labor 
and  pains. 

It  was  not  long  before  Dr.  Noyes  developed  his  ideas 
in  relation  to  eye  strain,  and  accepting  Dr.  Stevens' 
system  of  appealing  to  the  muscles  for  diagnosis  and  treat- 
ment free  from  the  accommodative  act,  he  was  able  to 
lay  before  the  profession  the  most  clear  and  well  balanced 


HAZEN'S   NEW   FINDINGS  137 

analyzation  of  the  subject  that  had  yet  been  published. 
His  writings  show  infinite  pains  taken  in  the  subject, 
with  study  clinically  made  and  with  a  mind  free  from 
prejudice  and  dogmatism. 

He  gave  much  hope  and  encouragement  to  those  fol- 
lowing out  the  lines  of  his  procedure.  There  has  not 
been  sufficient  attention  paid  to  his  emphatic  assertions, 
contrary  to  the  doctrine  of  Prof.  Donders,  regarding 
the  relation  of  Asthenopia  and  Hypermetropia. 

About  this  time,  there  were  two  modes  of  dealing  with 
that  perplexing  disease,  asthenopia;  they  were  antago- 
nistic to  each  other,  one  regarding  the  muscles  as  the  seat 
of  a  high  percentage  of  causes,  and  attention  was  directed 
to  its  relief  through  this  avenue,  the  other  believing 
that  the  whole  trouble  lay  in  errors  of  refraction  and  that 
if  the   muscles  were  implicated,   it  was  from   ametropia. 

Dr.  Stevens  was  an  active  worker  in  the  former  method, 
and  he,  with  Dr.  Ranney,  was  an  exponent  of  tenotomy,  a 
shortening  or  lengthening  of  the  muscles  to  obtain 
equilibrium.  They  mention  orthoptic  treatment  but 
relied  on   surgery  to   a  great  extent. 

They  taught  the  doctrine  of  "latent  heterophoria"- 
a  condition  where,  in  the  ordinary  means  of  examination 
the  full  amount  of  heterophoria  is  not  manifest.  Dr. 
Ranney  uses  the  word  "insufficiency"  synonomously 
with  heterophoria,  and  says,  "it  seems  to  him  to  be  a 
congenital  defect  in  most  cases,  probably  all."  The 
"latent  insufficiency"  of  the  internal  recti  he  makes 
manifest,  by  putting  on  a  pair  of  prisms,  bases  in,  in 
spectacles,  and  has  the  patient  wear  them  a  few  days. 
After  the  latent  becomes  manifest,  he  is  enabled  to  judge 
of  the  effect  he  wants  to  produce  in   his  tenotomy. 

Eyes  that  show  orthophoria  or  a  slight  amount  of 
heterophoria  before  wearing  the  prisms,  will  show  a 
considerable    amount    of    heterophoria.     This    is    but    in- 


138  HAZEN'S  NEW  FINDINGS 

dulging    i he    muscles,    which,    very    naturally,    take    the 
position  that  is  the  easiest  for  them. 

There  was  a  large  faction  in  the  profession,  who,  from 
natural  conservative  tendencies — perhaps  having  tried 
the  radical  method  of  tenotomy,  and  not  having  found 
what  was  expected,  fell  back  upon  the  doctrines  of  Don- 
ders  and  relied  upon  the  correction  of  ametropia.  Some 
have  gone  so  far  as  to  hold  that  if  relief  was  not  had,  it 
was  because  they  had  not  skill  enough  to  find  the  error. 
All  saw  a  deficiency  of  strength  in  the  muscles,  but  held 
that  the  cause  of  such  a  condition  was  the  uncorrected 
ametropia. 

A  few  prominent  men  did  not  believe  in  Muscular 
Asthenopia.  But  Dr.  Noyes  re-discovered  what  Bohn 
and  Rueta  promulgated  before  Donders  but  which  was 
obscured  and  set  in  the  background  by  the  brilliancy  of 
the  Professor's  System  of  Refraction.  The  patience  and 
systematic  analyzation  shown  in  Dr.  Noyes'  work;  his 
devising  of  means  to  discipline  the  muscles  by  a  suc- 
cession of  prisms,  and  the  true  estimate  he  made  of 
tenotomy  have  just  begun  to  be  appreciated  in  the 
settling  of  a  rational  view  to  be  held  in  the  future  regard- 
ing this  wide  spread  affliction. 

Most  authors  now  suggest  orthoptic  exercise  of  the 
muscles,  but  there  is  evidently  but  little  faith  in  its 
efficacy  as  practiced  by  them  This  is  easilv  accounted 
for  in  the  inefficiency  and  awkwardness  of  the  method. 
Two  authors  from  whom  I  have  quoted  say,  "that  the 
prisms  from  the  Test  Case  are  sufficient  to  carry  out  this 
treatment."  These  prisms  are  generally  ground  rouind 
edge  and  are  to  be  held  in  the  hand  of  the  practitioner, 
or  slipped  into  the  trial  frame  found  in  the  case.  When 
we  realize  that  the  manipulation  of  lenses  and  the  putting 
on  and  taking  off  of  prisms  from  the  faces  of  these  patients 
is  a  severe  ordeal  to  them,  and  that  the  axis  of  the  lens 
cannot  always  be  right,  and  that  too  the  strength  of  the 


HAZEN'S  NEW   FINDINGS  139 

lens  is  augmented  from  2°  to  6°  above  the  index  of 
the  lens  (varying  in  amount  by  the  position  of  the  plane 
of  the  lens  and  the  strength  of  it)  we  can  easily  see  the 
inaccuracy  of  the  act  and  the  unscientific  method  of  the 
manipulation.  However  dextrous  the  manipulator  may 
be,  he  will  increase  the  nervousness  of  the  patient  and 
will  not  get  the  accurate  information  that  is  needed. 

The  touching  of  the  eye  lashes  or  eyebrows  in  handling 
lenses  before  the  eyes  of  these  patients,  whether  the  lenses 
are  single  or  put  in  prisms  or  in  batteries  with  a  succession 
of  lenses,  is  extremely  annoying  and  irritating.  These 
patients  are  generally  nervous  and  motion  is  the  bane 
of  their  existence.  The  most  careful  manipulator  will 
often  cause  nausea  and  headache  or  irritability,  and 
either  the  patient  or  the  surgeon  will  give  it  up  in  disgust. 
Therefore,  the  practice  of  presenting  a  lens  before  the 
the  eye  for  correction — then  laying  it  down  and  taking 
up  and  presenting  another,  and  so  on,  is  entirely  wrong. 
The  practice  of  parting  the  light  and  asking  the  patient 
to  fuse  it,  and  if  unable  to  do  so,  to  present  another,  is 
another  mistaken  manipulation.  The  information  re- 
quired in  getting  the  duction  powrer  of  a  muscle  cannot 
be  obtained  in  this  way. 

There  is  much  stress  put  upon  ascertaining  the  devia- 
tion of  the  muscles  from  parallelism  (Heterophoria)  and 
many  tests  and  trials  are  made,  and  repeated  on  different 
days,  to  get  the  balance.  When  gotten,  the  information 
is  of  little  value  towards   a   solution  of  the  case. 

The  latest  writers  have  so  developed  the  imbalance 
theory  as  to  give  it  a  different  meaning  from  that  on  the 
basis  of  heterophoria,  which  we  have  had  for  some  time, 
so  that  now  the  definition  has  become  obscure,  and  almost 
lost  in  the  development  of  this  theory  of  equilibrium. 

Equilibrium  seems  now  to  be  an  imaginary  fulcrum, 
situated  somewhere  between  the  eyes,  behind  the  balls 
and  with  some  six  points  extending  through  the  aria  of 


L40  HAZKN'S    NKW    FINDINGS 

motion  of  the  eyes,  and  subject  to  as  great  variation  as 
an  aeroplane.  The  whole  object  to  be  obtained  in  the 
treatment  of  the  disorder  of  this  function  is  a  balance 
of  equilibrium. 

If  Tenotomy  is  not  resorted  to  immediately,  a  process 
is  adopted  of  changing  the  load  to  another  muscle,  or 
giving  it  more  or  less  action  by  changing  the  denomina- 
tion of  the  lenses  or  decentering  them,  or  putting  the 
cylinders  at  a  different  axis,  expecting  by  this  means  to 
counterbalance   this   imaginary   plane   to   an   equilibrium. 

\\  hen  these  appeals  to  the  refraction  part  of  the  eye 
prove  of  no  avail  in  curing  the  asthenopia,  tenotomy  is 
resorted  to,  or  at  least  that  dernier  resort  is  presented 
to  the  patient  with  emphasis — a  six  months'  vacation, 
travel  and  rest  to  build  up  the  constitution  is  recom- 
mended. 

That  the  delicate  and  intricate  apparatus  of  adjust- 
ment of  the  balls  should  not  have  troubles  of  their  own, 
per  se  is  contrary  to  our  experience  and  observation  of 
the  human  frame.  This  apparatus  in  the  function  of 
vision  is  as  complicated,  and  shows  as  many  contin- 
gencies in  its  participation  as  the  focal  act,  and  when  we 
consider  the  demand  upon  this  organ  in  the  work  of  our 
civilization,  we  must  expect  and  look  for  trouble  in  these 
parts  themselves.     It  is  reasonable  to  expect  to  find  it. 

The  investigation  of  the  muscular  system  commenced 
in  the  necessities  of  the  internal  recti,  for  the  severity 
of  their  work  in  convergence  was  noticed.  By  the 
giving  out  of  the  convergence  muscles,  attention  was 
called  to  the  opposing  muscles  and  the  abductors  became 
a  study  and  so  the  lateral  pairs  were  fully  brought  into 
notice,  but  the  verticals  and  the  obliques  were  yet  in 
the  undiscovered  physiological  world.  Those  who  brought 
into  training  the  laterals  let  the  verticals  go  untrained, 
and  whereas   the  laterals  were  voked   and  "broken''   the 


HAZEN'S   NEW    FINDINGS  141 

verticals    received    no    attention    or    were    handled     very 
differently. 

This  failure  to  get  results  in  the  vertical  muscles  may 
be  accounted  for  in  that  there  was  an  attempt  to  treat 
them  with  the  same  denomination  of  prisms  as  were  used 
in  the  cases  of  the  laterals,  and  not  getting  response, 
these  muscles  were  prismed  and  sometimes  clipped  or 
let  alone  and  considered  outside  of  the  general  laws  of 
extrinsic  muscles. 

THE  AUTHORS  FINDINGS. 

In  a  practice  of  the  Specialty  of  Eye  and  Ear  for  over 
forty  years,  and  adjusting  Compound  glasses  since  1869 
in  the  State  of  Iowa,  I  may  be  pardoned  for  considering 
my  experience  as  of  some  weight  and  value  in  the  relief 
of  Eye  Strain. 

With  the  best  facilities  to  be  had  during  this  period, 
and  with  as  close  and  skillful  attention  as  I  could  command, 
there  were  many  cases  that  were  not  relieved  to  the 
extent  that  one,  doing  such  work,  would  naturally  desire. 

The  subject  of  the  muscles,  during  this  period,  was  an 
obscure  one  but  my  study  of  it  resulted  in  the  belief  that 
there  were  a  great  many  suffering  from  nervous  troubles, 
which  could  be  accounted  for  in  eye  deflections,  and  that 
if  there  was  a  trouble  of  the  extra  ocular  muscles,  which 
explained  the  want  of  its  relief  by  correction  of  the 
refraction,  gymnastics  ought  to  be  of  some  service  in  the 
restoration  of  the  disability. 

The  directions  of  the  books  to  acomplish  gymnastics 
were  tried,  but  the  labor  of  it  was  sufficient  to  deter  one 
from  carrying  out  the  directions,  and  the  patients  would 
drop  off  before  accomplishing  what  was  set  out  to  be  done, 
and,  as  a  natural  consequence,  the  practice  of  muscular 
discipline  for  asthenopic  symptoms  gradually  fell  into 
disuse. 


142  HAZEN'S   NEW   FINDINGS 

Still  believing  in  the  principle,  although  the  practice 
in  it  failed,  I  had  batteries  etc.,  made,  upon  principles, 
which  1  thought,  from  my  experience  with  them,  were 
necessary. 

This  apparatus  was  in  my  hands  for  seven  years 
before  I  found  the  systematic  use  of  it  in  these  cases  of 
Functional  troubles.  Two  or  three  cases  fell  into  my 
hands  in  1896,  which  had  been  glassed  and  carefully 
treated  according  to  the  doctrine  of  Refraction  and  not 
relieved.  I  commenced,  and  carried  out  empirically  the 
treatment,  which  is  essentially  that  which  I  have  followed 
ever  since  with  gratifying  results.  I  have  deduced  and 
worked  upon  the  following  principles. 

1st.  The  diseases  presented,  formerly  designated 
asthenopia  and  now  termed  eye  strain,  are  disordered 
junctions  and  consist  in  weakness  or  insufficiency  of  the 
eye  muscles,  intrinsic  and  extrinsic,  and  the  chief  symptom 
is  asthenopia. 

2nd.  This  weakness  is  found  in  cases  of  emmetropia 
or  orthophoria  as  well  as  in  ametropia  or  hetrophoria; 
caused  from  overwork  of  the  eyes,  or  from  the  general 
need  of  tone,  refractive  error  or  the  absence  of  proper 
nourishment  by  aliment  for  assimilation. 

3rd.  When  the  refraction  is  hypermetropic,  unless 
there  is  an  extra  compensation  of  muscular  strength  in 
the  ciliary,  focusing  becomes  a  burden;  or  when  there  is 
heterophoria,  a  like  compensation  is  wanting,  the  excur- 
sion of  the  extrinsic  adjustment  is  lengthened  and  made 
difficult,  and  the  eye  balls  lag  and  mal-position  is  the 
consequence.  In  either  case  fatigue  is  experienced  and, 
unless  there  is  great  apathy  asthenopia  sets  in. 

4th.  This  weakness  may  be  from  obstruction  in  the 
eye  tissues;  it  may  be  from  an  imperfect  conducting 
quality  of  the  nerves  supplying  the  muscles;  it  may  be 
from  a  want  of  nervous  force;  lastly,  it  may  be  in  a  defect- 


HAZEN'S   NEW   FINDINGS  143 

ive  brain  (central).  All  of  these  causes  of  weakness  may 
be  considered  as  weak  innervation. 

5th.  The  indications  are  (if  this  theory  be  true)  to 
overcome  the  weakness  by  administering  those  aids 
which   strengthen   muscles   and   innervate   them. 

6th.  The  principal  aid  in  strengthening  muscles  is 
gymnastics.  The  effect  gained  by  this  means  remedies 
the  various  pathological  conditions  mentioned,  and  makes 
the  muscles  effective.  All  the  extrinsic  muscles  are 
equally  amenable  to  this  appeal,  when  a  proper  varia- 
tion is  made  under  the  general  laws  governing  all  of  them. 

Nature-Aids. 

In  view  of  the  conditions  which  we  pronounce  depart- 
ures from  the  normal  or  from  the  standards  we  set  up, 
the  most  rational  conception  seems  to  be  that  nature 
strives  to  mend  or  correct  these  defects  that  interfere 
with  the  action  for  which  eyes  are  made,  or  re-constructs 
or  fits  them  for  the  work  which  their  environment  has 
put  upon  them,  and  it  is  the  business  of  the  Doctor  to 
aid  Nature  in   accomplishing  this. 

Science  tells  us  that  in  the  progress  of  the  species,  the 
orbits  have  been  brought  around  toward  the  median 
line  from  90°,  found  in  the  fishes  and  most  of  the 
birds,  to  man  whose  orbits  diverge  but  24°  or  30°,  and 
we  know  that  the  eyeballs  can  be  maintained  at  paral- 
lelism within  these  diverging  sockets,  and  not  only  that, 
but  under  the  necessity  of  convergence,  man,  to  do  his 
tasks,  is  enabled  to  converge  50°  inside  the  median  line. 

From  this  history  of  the  organ  of  sight  in  the  past 
ages  and  the  conditions  we  rind  in  our  study  of  the  human 
eye,   we  can   draw  a   lesson. 

It  is  safe  to  regard  the  functions  of  the  organ  with 
which  we  are  dealing,  as  well  as  those  of  many  others  of 
the  human  system,  as  under  our  control  under  the  laws 


144  HAZEN'S   NEW    FINDINGS 

of  development,  and  to  note  that  changes  are  contin- 
ually going  on  for  better  or  for  worse;  that  man's  do- 
minion oil  the  earth  shows  a  wonderful  power  in  directing 
and  fashioning  the  species,  and  in  regulating  and  im- 
proving the  functions  and  moulding  the  good  qualities 
in  his  own  race,  or  in  animals  over  which  he  has  control. 

Then  it  is  reasonable,  in  the  present  application,  to 
remove  those  things  which  prevent  good  action  in  this 
function;  to  administer  to  the  weakness,  and  tone  up 
the  innervation,  and  use  any  other  means  that  will 
strengthen,  giving  Nature  a  chance  to  right  up  all  im- 
balances  if  these  interfere  with   proper  functioning. 

But,  if  after  this  attention,  the  eye  balls  do  not  take 
the  position,  which  is  found  necessary,  it  may  be  advis- 
able to  shorten  or  lengthen  muscles,  so  that  there  may  be 
less  expenditure  of  nerve  force  in  accomplishing  the 
excursion  needed  for  adjustment,  but  not  before  the 
orthoptic  treatment  has   been  well  tried. 

There  has  not  been  a  proper  recognition  of  this  con- 
dition and  very  poor  treatment  of  i*.  If  the  theory, 
that  Nature  is  bending  her  forces  to  th<„  accomplishment  of 
the  demands  of  environment  is  true,  there  will  be  but  few 
cases  for  such  interference,  for  she  is  wonderful  in  the 
adaptation  of  means  to  ends.  My  experience  is,  that 
surgical  interference  is  not  required  in  exophoria  at  all, 
if  there  is  vision  or  even  perception  of  light  in  the  devia- 
ting eye.  I  have  operated  by  advancement,  on  these 
cases,  for  years. 

CLASSIFICATION  BY  POSITION. 

Heterophoria. 

Heterophoria  is  most  likely  to  be  one  of  the  conse- 
quences of  weakness  or  of  pathological  conditions,  and 
not  heterophoria  the  cause  of  asthenopia.  In  Hetero- 
phoria   the    excursions  of  the  eye    balls  to  prevent    dip- 


HAZEN'S  NEW   FINDINGS  145 

lopia  for  distance,  is  greater  than  in  Orthophoria.  This 
requires  more  expenditure  of  nerve  force,  and  weari- 
ness is  apt  to  show  itself,  and  perhaps  pain.  The  func- 
tion act  starts  with  a  deficit,  as  Donders  said  of  Hyper- 
metropia.  If  the  nerve  supply  is  sufficient,  the  work  not 
protracted  beyond  limit  of  capacity,  or  the  heterophoria 
not  too  great,  there  is  but  little  inconvenience. 

Exophoria. 

Hypermetropia  causes  weakness  of  the  ciliary  from 
overwork,  and  we  have  accommodative  asthenopia. 
This  condition  is  properly  helped  by  convex  glasses,  but 
the  former  stimulus  given  to  convergence  by  the  excessive 
accommodation,  is  removed  by  the  glass,  and,  unless 
there  was  formerly  excessive  convergence,  the  internal 
recti  are  now  relieved  of  this  stimulus  and  they  are  thrown 
into  an  independent  condition.  This  developes  weak- 
ness and  muscular  asthenopia  often  arises  from  it, 
and  exophoria  is  developed.  This  course  of  reasoning 
is  properly  applied  to  the  insufficiency  of  the  internal 
recti  and  to  the  causes  of  exophoria  in  hypermetropia, 
of  which  the  writer  has  found  a  large  number.  \\  here 
there  was  but  little  weakness  at  the  beginning,  this  brought 
on  exophoria  and  for  every  degree  of  divergence,  there 
was  additional  necessity  for  effort  and  nervous  energy 
to  cover  the  gap,  that  was  continually  widening  as 
exophoria  was  developed,  and  until  the  patient  could 
learn  to  suppress  the  image  of  the  deviating  eye,  there 
was  continual  labor  and  pain.  Asthenopia,  however, 
subsides  as  the  effort  to  fuse  the  images  is  given  up, 
but  this  is  at  a  great  cost  of  useful  vision  to  that  ball 
and  to  the  patient's  ability  to  avoid  danger  to  his  person, 
and  I  may  add — to  the  looks  of  his  face. 

It  is  not  yet  established  that  all  eyes  should  be  made 
emmetropic  by  glasses.  Besides,  the  interference  con- 
vex  glasses    have   with   convergence,    it    is   quite   certain 


14C  HAZEN'S  NEW  FINDINGS 

that  hypermetropia,  if  not' great,  is  a  better  condition  for 
a  healthy  development  of  the  eye  in  children  than  em- 
met ropia. 

ESOPHORIA. 

In  esophoria  the  external  recti  have  the  load  in  respect 
to  distant  vision,  but  if  of  moderate  degree,  say  8°  or 
less,  when  there  is  abduction  sufficient,  there  is  an  advan- 
tage in  the  act  of  convergence — that  is,  if  there  be  no 
undue  action  or  spasm  of  the  internal  recti.  The  ball 
is  in  or  near  the  position  for  near  vision,  without  the 
necessity  of  the  convergence  act.  Nevertheless,  in  these 
esophoric  cases  there  is  weakness  of  adduction,  with  as 
high  degree  of  esophoria  as  8°,  and  to  cure  the  asthenopia, 
adduction  has  been  given,  but  abduction  should  also 
be  attended  to  before  discharging  the  case.  The 
esophoria  may  increase,  but  long  before  adduction  has 
been  brought  to  the  standard,  the  asthenopia  will  have 
vanished.  Often  the  esophoria  increases  in  exercise 
of  the  adductors  even  as  high  as  14°  and  the  patient 
is  discharged  in  this  condition,  but  in  a  short  time,  the 
lateral  muscles  will  be  found  to  be  towards  orthophoria. 
If  the  abductors  are  strong,  the  needful  movement  is 
easily   made   to   parallelism. 

Hypirihoria. 

The  verticals  have  been  the  last  of  the  muscles  to  be 
recognized  as  participating  in  this  wride  spread  affliction. 
Although  Drs.  Stevens  and  Noyes  found  hyperphoria 
and,  with  it,  severe  trouble — the  remedy  was  to  put  prisms, 
with  base  up  or  down,  into  spectacles.  These  of  course 
relieved  for  a  time,  but  soon  a  greater  degree  of  hyper- 
phoria developed  and  stronger  prisms  were  prescribed, 
until  the  indulged  muscles  allowed  the  eyre  to  hide  under 
the  lid,  and  a  delicate,  uncommon  and  skillful  graduated 
tenotomy  is  consented  to,  by  the  patient. 


HAZEN'S   NEW    FINDINGS  147 

Having  discovered  the  right  denomination  of  lenses 
and  the  proper  interval  between  them,  I  found  that 
orthoptic  treatment  was  as  efficacious  on  one  pair  as 
any  other  pair,  and  that  they  all  responded  equally  well 
and  were  equally  amenable  to  the  general  laws  of  eye 
muscles. 

Cycloj  hor  a. 

The  oblique  muscles  have  command  of  the  torsion 
or  wheel  motions  of  the  eye.  The  normal  position  of  rest 
— the  vertical  axis  of  the  upper  end — is  said  to  be  about 
three  degrees  outward  of  the  vertical  line.  "Every 
motion  of  an  eye  from  the  primary  to  an  oblique  posi- 
tion is  accompanied  by  torsion  as  an  essential  com- 
ponent of  the  motion."  Maddox.  This  was  recognized 
by  Donders,  Helmholtz  and  developed  in  Lystings' 
Law. 

In  oblique  astigmatism  the  oblique  muscles  are  called 
upon  to  correct  it,  so  that  the  axis  of  vision  may  cor- 
respond to  the  vertical  and  horizontal  lines,  of  which 
print   and   objects   generally   are   made   up. 

To  Dr.  Savage,  we  owe  the  discovery  of  the  "Ineffi- 
ciency of  the  oblique  muscles."  and  a  method  of  clearly 
and  easily  detecting  it.  I  have  not  had  satisfactory 
results  in  treating  it  with  cylinders,  as  he  recommends. 
We,  of  course,  correct  astigmatism  that  may  cause  the 
overwork  of  the  oblique  muscles,  and  treat  for  strength- 
ening the  obliques  the  same  as  we  do  the  verticals.  It 
often  disappears,  without  direct  appeal,  in  treating  the 
recti. 

My  observation  and  experience  in  treating  these  cases 
of  eye  strain  is,  that  it  may  come  in  the  emmetropic 
and  orthophoric  eye  as  frequently  as  in  the  ametropic 
or  heterophoric  eye,  and  weakness  of  the  ciliary  muscle 
or  of  the  external  muscles  may  come  as  well  in  one  as 
in  the  other,  accommodation  becoming  difficult  and  con- 


L48  NAZI-: N •  S    X K W    PI N DINGS 

mergence  painful;  soreness,  nervousness  and  inability 
for  protracted  work  are  present,  but  accommodation 
may  show  normality  and  there  be  no,  or  very  little, 
deviation  of  the  muscles.  The  inclination  is  to  favor 
the  muscle,  and  the  common  idea  is  to  rest  and  avoid 
use  when  they  hurt,  and  there  is  developed,  "insufficiency" 
and  in  many  cases  exophoria.  When  a  phoria  is  devel- 
oped, it  adds  labor  to  the  muscle  of  adjustment;  the 
excursion  of  the  eyeball  to  accomplish  a  fixation  becomes, 
more  and  more,  an  extra  task.  That  the  trouble 
should  be  supposed  to  be  in  the  deflections  or  the  heter- 
ophoria,  seems  to  me  a  great  mistake.  For  the  classi- 
fication of  these  cases,  we  will  group  them  differently. 

CLASSIFICATION   BY   PATHOLOGICAL   CONDITIONS. 
Vascularity. 

Prof.  Donders,  in  speaking  of  the  fatigue  of  the  mus- 
cles, mentions  as  the  result  of  the  performance  of  labor, 
"the  products  of  metamorphosis  of  matter  in  the  muscle 
tissue." 

This  physiological  condition  may  be  the  explanation 
of  a  pathological  state,  which  we  find  in  a  group  of  cases 
with  symptoms  of  eye  strain.  This  group,  which  is 
characterized  by  a  hyperemic  condition,  is  of  wide  extent. 
The  patient  may  have  this  hyperemia  for  years  without 
the  characteristic  of  inflammation,  (the  sticking  together 
of  the  lids  in  the  morning)  which  shows  the  dividing 
line  between  hyperemia  and  inflammation.  With  some, 
there  is  a  tearing  and  with  others  a  dry  hot  sensation. 
There  is  a  general  vascularity  inside  (opthalmoscopic- 
ally)  and  out.  In  the  advanced  or  chronic  stage, 
stys  and  pterygium  may  be  developed.  The  patient 
soon  learns  to  school  himself  to  avoid  motion  of  the  eye 
balls  because  of  the  pain  in  friction  of  the  balls  and  lids; 
the  eye  takes  on   a   dull  sunken  and  soggy  appearance, 


HAZEN'S   NEW   FINDINGS  149 

and  the  individual  mopes  and  subdues  all  impulses  to 
animation,  and  looks  disconsolate  and  spiritless.  Every 
act  of  fixation  blurs  and  most  sufferers  pass  the  fingers 
or  knuckles  across  the  lids  every  few  minutes,  they  take 
off  their  glasses  to  press,  or  squeeze  the  balls  by  strong 
closing  of  the  lids,  which  press  upon  the  balls  and  take 
off  the  tension  of  the  muscles  for  a  moment  and  perhaps 
accelerate  the  circulation  to  absorption.  They  school 
themselves  not  to  fix  upon  an  object,  and  allow  motions 
and  other  things  to  happen  before  their  eyes  without 
notice,  and  in  walking  on  the  street  avoid  observation. 
For  this  purpose,  they  wear  black  glasses  and  attribute 
their  pain  to  intolerance  of  light.  These  cases  are  not 
characterized  by  great  nervousness,  excitableness  or 
sleeplessness. 

I  believe  they  may  be  classified  as  reflection  of  eye 
strain  on  the  Yaso-Motor  System.  It  is  remarkable 
how  quickly  these  cases  respond  to  proper  treatment  by 
gymnastics. 

Neuralgia  and  Neurasthenia. 

Another  group  of  asthenopic  symptoms  is  found  when 
the  patient  suffers  through  reflex  on  the  fifth  nerve  sys- 
tem. Ranney  in  "Nervous  Diseases"  says,  "The  causes 
of  neuralgia  may  be  classified — (1)  The  predisposing — 
(2)  modifying — (3)  exciting,"  and  says  under  the  first, 
"I  believe,  from  somewhat  extended  research,  into  the 
probable  factors  which  tend  to  induce  the  neuropathic 
tendency,  that  the  eye  strain  and  abnormal  eye  tension 
are,  perhaps,  more  closely  related  to  the  obscure  and  im- 
perfectly understood  conditions  than  any  other  factors, 
which  have  yet  been  observed." 

"As  a  rule,  it  may  be  stated  that  neuralgias  are  seldom 
dependent  upon  pathological  changes.  In  a  few  excep- 
ional  cases,  however,  the  nerves  and  the  nerve  centers 
ma>'  reveal,  in  a  variety  of  ways,  the  existence  of  a  mor- 


150  HAZEN'S   NEW  FINDINGS 

bid  state."     "We  are  forced  to  admit  that  the  pathology 
of  neuralgia  is  not  yet  understood." 

"All  the  later  observations  of  Dr.  Stevens  and  myself,'' 
he  says,  "go  to  show  that  neuralgic  attacks  are  curable 
in  a  large  proportion  of  cases,  when  treated  by  the  relief 
of  eye  strain" ....  "Like  other  purely  functional  neuro- 
sis, the  detection  of  the  cause  and  the  removal  of  the 
irritation  (generally  of  a  reflex  type)  results  in  the  per- 
manent benefit  of  the  .patient,  and  a  more  or  less  com- 
plete cessation  of  the  attacks. 

Dr.  Joseph  Collins  (J.  A.  M.  A.  Jan'y  '09)  says,  "Ner- 
vous Diseases  are  looked  upon  as  mysterious  in  their  mani- 
festations, incomprehensible  in  their  display,  unamenable 
to  treatment  and  therefore  unworthy  of  profound  effort 
at  interpretation."  Functional  or  Organic?  There  are 
diseases  in  which  no  characteristic  anatomic  alterations 
are  found  after  death,  and  yet,  we  believe  these  to  be 
organic  diseases.  Among  these  are  paralysis  agitans, 
grave  myasthenia  and  hyperthyroidism.  There  are 
other  diseases  commonly  spoken  of  as  diseases  of  degener- 
acy or  deviation  such  as  tic,  hysteria,  idiopathic  epilepsy 
and  psychosthenia,  possibly  migraine,  which  are  not 
likely  to  be  found   associated  with   anatomic   alteration. 

Dr.  Collins  further  says,  "There  seems  to  be  something 
about  functional  nervous  diseases,  which  is  decidedly 
repellant  to  many  members  of  our  guild ...  .Another 
feature  of  his  attitude  is  the  belief,  feeling  or  assumption, 
that  these  diseases  are  not  real,  that  they  are  more  or 
less  assumed,  that  they  are  manifestations  of  weakness 
of  contumacy,  that  they  are  a  sort  of  splotch  on  the 
escutcheon  of  health  and  of  moral  dignity,  that  they  are 
evidences  of  stubborn  perverseness,  which  excite  a  min- 
gling of  sympathy  and  contempt,  that  they  are  products 
of  disordered   imagination." 

"This  is  a  distinct  sequel  of  the  view  which  looked  on 
functional  nervous  diseases  as  manifestations  of  demon- 


HAZEN'S   NEW    FINDINGS  151 

iacal   possession,    and    it    is    much    less    prevalent   than    it 
was  a  generation  ago." 

It  is  not  to  be  wondered  at  that  nervous  diseases  are 
so  little  understood  and  that  their  phenomena  are  a 
mystery.  \\  hen  we  remember  what  the  system  of 
refraction  has  done  in  the  last  fifty  years,  in  relieving 
headache,  we  marvel  that  even  in  our  time,  books  have 
been  written  on  headache,  without  a  mention  of  Eye 
strain  as  a  cause.  Dr.  David  Webster  saved  the  credit 
of  Dr.  J.  Leonard  Comings'  work  (1894)  on  "Headache 
and  Neuralgia,"  in  an  appendix  on  eye  strain.  Francis 
E.  Anstie  on  "Neuralgia"  (1872)  has  not  a  word  to  say 
about  the  part  that  eye  troubles  have  in  producing 
Neuralgia. 

Taking  the  relation  of  Nervous  Disease  men,  and 
oculists,  they  seem  to  be  as  far  apart  as  two  religions. 
Although  they  graduate  at  the  same  schools  and  study 
the  human  system  together,  they  have  but  little  con- 
sultation over  those  diseases  in  which  both  should  be 
familiar  with  each  other's  experience,  if  they  would 
master  all  difficulties. 

If  one  half  of  what  that  indefatigable  writer,  George 
M.  Gould,  says  in  regard  to  eye  strain  and  the  benefits 
derived  from  glass  fitting  be  true  ,  and  if  to  this,  there 
can  be  added  the  additional  cause  of  affection  of  the  mus- 
cles, we  may  truly  believe  that  the  specialist  of  the  "Eye" 
has,  within  his  grasp,  the  majority  of  the  neuralgic 
ailments  of  civilized  man. 

Reflexes. 

The  power  of  eye  strain  for  making  mischief  in  remote 
parts  by  reflex  action,  is  hardly  recognized  anywhere  in 
general  medical  literature,  yet,  there  have  been  reports 
of  surprising  relief  by  the  fitting  of  glasses  or  the  correc- 
tion of  muscular  anomalies. 


152  HAZENS  NEW   FINDINGS 

People  who  had  been  unable  to  read  a  book  for  twenty 
years  have  been  restored.  Some,  who  had  suffered  from 
migraine  for  a  quarter  of  a  century,  have  been  almost 
miraculously  cured  by  skillful  manipulation  about  the 
eye,  but  the  Medical  profession  is  so  slow  to  accept,  that 
the  pressure  to  its  recognition  will  have  to  come  through 
the  education  by  popular  reading,  and  advertisements 
among  the  less  educated,  rather  than  through  the  teach- 
ing of  those  who  are  the  best  judges  and  who  are  able  to 
test  the  experiences  of  their  own  confreres. 

There  are  people  dying  in  every  community  from  asthen- 
opia as  a  first  cause.  Young  people,  who  are  driven  to 
desperation  by  it,  sometimes  lose  command  of  them- 
selves and  go  to  the  bad,  because  they  are  unable  to  work 
as  others  do,  and  often  they  are  drawn  to  the  use  of  drugs 
or  stimulants. 

\\  e  are  unable  to  properly  judge  of  criminality  or  the 
cause  of  a  suicide,  until  we  inquire  about  the  nervous 
symptoms  and  learn  the  source  of  that  desperation. 

Nervous  diseases,  most  of  which  are  not  organic,  have 
been  classified  as  Neurasthenia,  Hysteria,  Chorea,  Epilepsy, 
Psychosis,  Insomnia,  Brain  fag,  Migraine,  Nervous 
prostration,  Sick  headache.  There  are  those  in  every 
community,  who  are  counted  invalids  and  who  are  un- 
able to  contribute  to  the  work  of  society;  they  are  unable 
to  read;  to  attend  church  or  theater;  they  often  spend 
half  of  the  day  in  bed.  There  are  others  who  are  on  the 
go,- — travel  and  work  off  the  surplus  vitality  by  activity, 
fearing  to  enter  the  arena  that  calls  for  near  work.  There 
are  many  others,  who  are  assigned  to  sanitariums — in- 
stitutions to  be  amused  and  to  rest — some  to  asylums, 
unlabeled.  I  believe  a  great  percentage  of  these  have 
asthenopia  as  a  first  cause. 

The  effect  of  asthenopia  is  exceedingly  variable.  One 
may  have  only  eye  symptoms,  perhaps  only  headache 
of  a  neuralgic  character.     It  may  occur  in  people  who  have 


HAZEN'S  NEW   FINDINGS  153 

an  extraordinarily  good  physique.  I  have  found  it  in 
athletes  who  had  good  digestion.  The  direction  taken 
in  the  reflex  contiguous  nerves,  depends  upon  the  power 
of  resistence  these  nerves  have  to  repel  an  attack.  In 
some  cases,  the  Fifth  nerve,  the  ophthalmic  branch  will 
succumb  to  the  irritation  and  neuralgia  sets  in  and  mi- 
graine developes.  Then  reflections  upon  the  general 
nervous  system,  denominated  neurasthenia  and  symp- 
toms become  widely  spread,  and  thus  require  a  more 
definite  classification,  familiar  to  all — named  nervousness, 
hysteria,    chorea,    nervous    prostration,    sick   headache. 

Sometimes  the  spinal  nerves  show  the  direction  or 
course  and  there  is  pain  at  the  occipit  or  base  of  the  brain, 
and  through  the  cervical  vertabrae,  and  there  is  tender- 
ness of  the  spine  and  numbness  of  the  extremities. 

When  the  pneumo-gastric  succumbs  to  the  attack,  we 
have  a  train  of  symptoms  that  may  wreck  a  life.  Aphonea 
ma}'  be  the  only  evidence  of  the  weakness,  but  the  heart 
is  often  affected;  with  migraine,  the  stomach  and  other 
digestive  organs  are  often  the  seat  of  the  most  severe 
symptoms  to  which  the  human  being  is  subjected.  When 
this  incubus  settles  upon  an  individual,  life,  as  witnessed 
by  the  observer  of  it,  does  not  seem  worth  the  living, 
and  were  it  not  that  there  were  intervals  of  cessation 
and  a  clearing  away  of  the  clouds,  and  the  sunshine  of 
existence  breaking  in  occasionally,  it  would  seem  that 
an  ending  would  be  preferred.  Such  a  life,  covering  a 
period  of  30  or  40  years — half  of  it  spent  in  bed  with 
intense  suffering,   is  a   marvel  of  tolerance. 

Mental. 

Yet  another  tangent  for  this  reflex  is  upon  the  mental 
faculties.  Included  under  this  head,  some  might,  with 
propriety  be  named,  "the  perverted  senses."  These 
attacks    often    come    suddenly,    a    wave   of   confusion,    a 


154  HAZBN'S   NEW   FINDINGS 

sudden    blindness,    dizziness,    an    unaccountable    fright, 
insomnia,  melancholia,  etc. 

That  the  diseases  named  in  this  category,  and  that 
8}  mptoms  difficult  to  be  explained,  have  their  origin  in 
eye  strain,  is  fast  being  admitted  and  proved,  and  that 
attention  to  the  eyes  tor  their  relief  is  not  to  be  ignored. 
The  relief  sometimes  comes  so  quickly,  that  it  has  been 
explained  as  having  some  relation  to  "suggestion" — 
mind-cure   or   psycho-therapy. 

The  many  groups  of  symptoms  that  have  been  devel- 
oped by  reflexes  generally  have  the  history  of  eye  trouble, 
but  not  always.  The  secondary  effect  becomes  of  pre- 
dominant importance  and  the  eye  as  the  leading  factor, 
is  forgotten;  the  secondary  disease  becomes  the  primary 
one,  and  the  attention  of  the  practitioner  is  wholly 
taken  up  in  combatting  the  symptoms  of  it  without 
recognizing  its  genesis. 

Xot  many  are  now  holding  out  against  the  assertions, 
that  sometimes  chorea,  hysteria,  epilepsy  ,etc,  are  cured 
by  correcting  the  cause  of  eye  strain. 

TREATMENT. 

The  principal  relief  that  has  been  reported  in  cases  of 
reflex  eye  strain,  is  that  of  the  correction  of  refraction 
and  tenotomy  of  the  muscles.  Dr.  Noyes  has  more 
fully  recognized  the  part  the  extrinsic  muscles  take  in 
asthenopia,  than  any  other  author  with  whom  I  am 
acquainted.  With  his  apparatus,  he  was  enabled  to 
demonstrate  the  efficacy  of  orthoptic  exercise,  but  his 
appliances,  although  an  improvement  on  those  before 
him,  lacked  very  many  essential  elements  to  meet  the 
indications. 

My  experience,  though  limited  considering  the  very 
broad  field  which  I  am  led  to  believe  is  spread  by  this 
octopus   of  human   ills,   has   but   partially  developed   the 


HAZEN'S   NEW    FINDINGS  lo5 

possibilities,   that   I    believe   exist,    in   an   intelligent   and 
systematic  treatment  of  the  motor  apparatus. 

I  find  that  this  apparatus  is  the  seat  of  the  trouble 
in  over  half  the  functional  difficulties;  and  the  cause  of 
many  other  eye  troubles;  that  a  very  high  percentage, 
if  not  all  of  those  cases  of  asthenopia,  which  are  attributed 
to  constitutional  causes,  are  eye  affections  causing  the 
disturbance  of  the  whole  economy.  When  the  muscles 
receive  as  much  attention  as  the  refraction,  it  will  dispose 
of  as  many  sufferers  in  addition,  as  has  the  fitting  of  glasses. 

I  find  that  the  excessive  emphasis  put  upon  the  appli- 
cation of  glasses  in  asthenopia,  is  beyond  good  judgment 
and  honesty. 

There  was  a  time  when  it  was  almost  impossible  to 
get  the  consent  of  the  parent  for  the  child  to  wear  glasses, 
but  the  people  are  now  so  well  educated  that  spectacles 
are  sought  when  complaint  is  made  of  the  eyes,  and  if 
relief  is  not  obtained  at  the  first  fitting,  a  second  is  tried 
by  the  same  practitioner,  or  the  patient  goes  to  another, 
and  so  much  faith  is  put  in  glasses  that  there  are  many, 
who  have  been  fitted  a  dozen  times  or  more. 

By  following  up  these  cases,  it  is  often  found  that  the 
variation  in  the  prescriptions  is  infinitesimal;  a  quarter 
dioptra  on  the  medium,  one  side  or  the  other,  or  a  slight 
change  in  the  axis  of  the  cylinder.  The  craze  for  fitting 
glasses  onto  every  one,  complaining  of  his  eyes  and  putting 
on  as  low  as  .25  D.  spherical,  and  sometimes  a  perfectly 
plain  glass  has  become  a  menace  to  good  morals  and 
borders  on  fraud. 

For  those,  who  have  not  learned  that  the  extrinsic 
muscles  have  as  much  to  do  with  asthenopia  as  errors 
of  refraction,  there  is  some  excuse.  There  are  some 
patients,  who  think  that  any  glass  benefits  them,  and 
when  once  put  on,  it  is  difficult  to  do  away  with  them 
until  the  muscles  are  made  right,  though  they  be  only 
.25   D.  or   even   plain   glasses,  but  the  slight  betterment 


156  HAZEN'S  NEW   FINDINGS 

comes  so  far  short  of  the  actual  benefit  they  might  have, 
that  it  seems  to  those,  who  know  the  situation,  that  it 
is  a  farce. 

By  experience,  I  have  come  to  the  conclusion  that 
in  young  persons  there  is  no  need  of  a  spherical  of  1  D. 
or  under,  or  a  cylindrical  of  .50  D.  when  that  cylinder 
stands  at  90°  or  180°.  It  has  been  said  that  there  is  much 
doubt  as  to  the  propriety  of  putting  low  powers  of  con- 
vex spherical  glasses  on  children.  Since  learning  that 
eye  strain  is  so  often  found  in  the  muscular  system, 
this  proposition  is  the  better  confirmed.  The  neutral- 
izing of  the  hypermetropia  is  taking  off  the  stimulus  in 
the  act  of  convergence  and  insufficiency  sooner  becomes 
manifest.  If  the  cylinder  that  corrects,  stands  obliquely 
even  in  low  powers,  it  is  often  necessary  to  wear  it, 
because  objects,  letters  and  other  things  are  made  up 
mostly  of  vertical  and  horizontal  lines.  Nearly  all 
cases  which  I  have  treated  for  asthenopia,  when  1  D.  or 
under,  voluntarily  took  off  their  glasses.  I  have  had  a 
large  number  of  cases,  who  had  a  refraction  of  +1.25  D. 
or  +1.50  D.  who  have  gone  without  their  glasses  for 
months  and  some  for  years,  and  some  of  them  are  very 
close  to  the  age  of  forty  years. 

The  facts  are  that  asthenopia  is  seated  in  the  extrinsic 
muscles  as  frequently  as  in  the  ciliary,  but  there  are  a 
few  who  have  pure  accommodative  asthenopia,  and  these 
are  relieved  by  correcting  the  refraction.  Most  accommo- 
dative asthenopia  is  associated  with  muscular  asthenopia. 
The  treatment  of  the  external  muscles  innervates  the 
ciliary  for  it  is  supplied  by  the  same  nerve.  The  dif- 
ferentiation of  Accommodative  and  Muscular  Astenopia, 
by  the  symptoms,  is  very  difficult. 

A  prominent  symptom  of  muscular  trouble  is  the  vic- 
tims' horror  of  motion;  it  is  the  bane  of  their  existence, 
and  they  soon  assume  a  stoical  manner  and  deny  them- 
selves   amusements    that    involve    motion    before    their 


HAZEN'S   NEW   FINDINGS  157 

eyes,  or  riding  which  gives  apparent  motion  to  fixed 
objects.  These  persons  suffer  most  at  sea,  for  sa'ling 
is  but  the  two  relations  acting  together. 

The  story  of  asthenopia  for  fifty  years,  as  told  in  these 
pages,  is  a  tale  of  general  neglect,  or  of  a  long  delayed 
recognition  of  the  participation  of  the  muscular  system 
of  the  eye,  in  the  wide  spread  affection  of  asthenopia; 
that  the  inefficient  methods  of  the  few,  who  have  found 
that  the  muscles  have  such  a  bearing,  that  the  work  of 
those  few  has  been  set  aside  and  the  treatment  they 
instituted,  ignored,  and  that  the  teachings  of  many 
authors  has  either  been,  that  there  is  no  such  thing  as 
"muscular  asthenopia"  or  that  all  asthenopia  can  be 
cured  by  correcting  the  ametropia,  and  on  the  other  hand, 
that  there  has  been  much  teaching  of  the  doctrine,  that 
muscular  troubles  are  an  imbalance  or  want  of  equili- 
brium, and  do  not  lie  in  the  pathological  weakness  of 
these  muscles  —  in  view  of  all  of  this,  I  recommend  a 
new  method  and  a  new  view  of  the  condition. 

In  consideration  of  the  fact,  that  the  method  instituted 
under  this  view,  has  been  tried  and  found  entirely  effica- 
cious in  relieving  a  large  number  of  persons,  who  had 
undergone  treatment  by  the  former  methods,  I  ask  for 
it  a  faithful  trial. 


158  HAZENS  NEW  FINDINGS 


THE  KRATOMETER. 
See   Figs.  II  and  III 

This  instrument  has  been  named  from  the  Greek  word 
Kratos  meaning  strength,  and  the  Latin  word  meter,  to 
measure. 

It  is  intended  to  carry  out  in  the  best  manner  possible, 
the  principles  found  necessary  in  the  examination  and 
treatment  of  the  Muscular  system  of  the  eyes,  on  the 
theory  that  eye  strain,  and  the  chief  symptom  asthenopia, 
are  situated  in  the  muscles,  intrinsic  and  extrinsic,  and  that 
trouble  of  the  extrinsic  constitute  at  least  half  of  the  cases 
of  asthenopia;  that  this  trouble  is  weakness,  from  some 
condition  of  the  tissue  of  the  muscles,  or  a  deficiency  of 
nerve  innervation  or  both  together,  and  that  muscular 
discipline  is  the  chief  method  of  correcting  the  anomalies. 
To  carry  out  this  method  to  its  best  consummation,  we 
find  it  necessary  and  most  convenient — 1st.  To  fur- 
nish in  the  instrument,  the  requisite  means  of  diagnosing 
all  the  anomalies  as  well  as  treating  all  the  abnormal 
conditions.  2nd.  To  afford  a  restful  situation  for  the 
person  while  being  examined  and  treated,  so  that  the 
nervousness  so  often  found  may  be  quieted;  to  protect 
the  region  of  the  face  and  eyes,  the  eye  brows  and  lashes 
from  being  touched  in  manipulation  of  lenses,  which 
often  occurs  in  the  usual  methods,  causing  nervousness, 
sickness  and  headache.  3d.  To  manipulate  the  lenses 
smoothly  and  with  facility,  at  right  axis  and  with  uniform 
intervals;  to  be  able  to  pass  the  requisite  number  of  lenses 
at  a  sitting  to  effect  the  purpose,  with  comfort  to  the 
patient  and  with   as   little  labor  as   possible. 


Fig    II. 
HAZEN'S    KRATOMETER 


For  Gymnastic  Treatment  of  the  Extrinsic  Muscles 
of  the  Eyes 

E.  H.  HAZEN,  M.  D.,  Ophthalmologist 
A.  W.  HAZEW  Optician 


Figs.  I  and  II — Stand. 

Figs.  Ill  and  IV — Head  with  Stem. 

Fig.  V — Phorometer  Slide. 

Figs.  VI  and  VII — Batteries. 


T 

n 

,; 

TLe^rr      ~Fic^rr 


A — Set  Screw. 

B — Clamp. 

C — Fingers  of  Clamp. 

D — Clamp  Screw. 

E — Battery  Guide. 

F — Set  Screw. 

G — Set  Screw. 


H — -Lens  Rest. 

I — Eye  Cup. 

J— Lens  Disk. 

K — Phorometer  Slide. 

L — Pulpilary  Aperture. 

M— Maddox  Plate. 

N — Red  Glass. 


EXAMINATION  OF  THE  PJIOKIA  161 

ITS     APPLICATION. 
Diagnosis. 

The  instrument  is  made  so  that,  when  screwed  to  a 
table,  the  vertical  and  horizontal  lines  are  correct.  The 
very  accurate  adjustment  necessitating  a  level  to  the  in- 
strument, is  superfluous.  A  general  attention  to  the 
table  used,  with  a  plum  line  and  square  is  all  that  is 
necessary.  The  height  of  the  instrument  should  be 
adjusted  by  the  height  of  the  stool  on  which  the  patient 
is  to  be  seated,  and  the  height  of  the  head  piece  in  the 
instrument,  which  is  fastened  by  a  clamp  screw.  The 
head  should  be  in  the  primary  position  and  the  P.  D. 
arranged.  The  apertures  in  the  cups  through  which  the 
patient  looks,  are  about  a  half  inch  in  diameter,  this 
size  being  found  large  enough  to  give  sufficient  field,  and 
small  enough  to  prevent  the  patient  from  deflecting 
the  head  to  correct  an  hyperphoria,  instead  of  by  action 
of  the  muscle. 

The  two  batteries  contain  15  lenses  each,  one  (the 
units)  has  an  interval  of  one  degree,  rising  from  1°  to 
15°  bases  on  the  side,  so  it  can  be  used,  base  in  or  out. 
The  other  battery  (fractional)  has  intervals  of  1-4°  with 
base  up  or  down  and  rises  to  3  3-4°. 

The  Phoria. 

The  phoria  or  balance  is  tested  by  use  of  the  Maddox 
Rod  and  Maddox  double  prism,  which  are  in  one  plate 
and  are  adjusted  before  the  R.  E.  and  a  red  glass  is  near 
in  the  same  slide  to  throw  over  the  L.  E.  as  occasion 
requires. 

Lateral  Muscles. 

To  get  the  balance  of  the  Lateral  muscles,  the  hori- 
zontal rod  is  placed  over  the  R.  aperture — if  the  streak 
of   light   which    it    produces,    is    through    the    light,    it    is 


162  HAZEN'S   NEW    FINDINGS 

orthophoria,  if  it  is  on  the  right,  we  have  esophoria — 
if  on  the  left,  it  is  exophoria.  By  carrying  the  units 
battery  up,  entering  the  least  degree  first  (base  cul) 
until  the  streak  is  through  the  light,  the  prism  that  brings 
it  into  this  position,  gives  the  amount  of  esophoria; 
if  the  battery  is  carried  down  (base  in)  the  amount 
required  to  bring  the  streak  into  the  light,  eives  the 
amount  of  exophoria. 

Verticals. 

The  exrmination  of  the  verticals  is  made  with  the 
Maddox  Rod  placed,  vertically  over  the  R.  E.,  which 
gives  the  streak  horizontally.  If  the  streak  is  below 
the  light,  we  have  R.  hyperphoria;  if  above,  it  is  L. 
hyperphoria.  This  is  measured  by  the  1-4°  batter}', 
passing  it  up  or  down  as  required.  In  examination 
of  the  verticals,  a  small  light  should  be  used,  or  a  light 
behind  a  small  aperture  of  a  half  inch  in  diameter. 

Oblique. 

To  detect  Cyclophoria,  bring  the  Maddox  double 
prism  over  the  R.  E.  and  direct  the  attention  to  a  hori- 
zontal line  20  ft.  distant.  The  patient  is  asked  to  put 
his  head  in  position  so  that  the  line  between  the  two 
prisms  is  midway  over  the  pupil,  when  he  will  see  the 
line  doubled;  on  opening  the  L.  E.  there  will  appear 
a  third  line  between  the  two;  if  the  line  is  parallel  to  the 
other  two  we  have  orthophoria  in  the  L.  E. 

If  the  line  dips  down  in  the  right  end,  the  superior 
oblique  of  the  left  eye  is  in  a  state  of  underaction;  if  it 
dips  to  the  left,  the  inferior  oblique  is  weak.  Reverse 
the  Phorometer  slide  so  that  we  can  examine  the  R.  E. 
with  the  Maddox  prism  over  the  L.  E.  When  the  right 
end  of  the  middle  line  runs  upward  the  superior  oblique 
of  the  R.  E.  is  weak;  if  the  left  end  of  the  middle  line 
turns  upward,  the  inferior  oblique  of  the  R.  E.  is  weak. 


CONVERGENCE  163 

Convergence  Rod. 

The  Kratometer  is  provided  with  a  Convergence  rod 
for  testing  accommodation  and  convergence.  It  is  marked 
with  Centimeters,  which  conforms  to  the  system  of 
Dioptries  and  Meter  Angles.      (Xagel) 

The  accommodation  is  measured  by  use  of  a  small 
card  with  print,  the  standard  of  Jaeger,  which  is  placed 
in  the  carrier  of  the  rod.  Xote  should  be  made  of  the 
centimeter,  where  the  print  begins  to  blur  in  reading 
the  card.  To  ascertain  the  convergence,  turn  the  card 
over  and  place  it  with  the  line  found  on  it  vertically; 
note  the  point  in  centimeters  where  the  line  becomes 
double.  Dividing  100  by  the  number  of  centimeters 
in  either  case,  will  give  you  the  dioptries  of  accommoda- 
tion in  one  case,  and  the  meter  angles  of  convergence 
in   the   other. 

Reading  Distance. 

A  test  at  the  reading  distance,  one-third  of  a  meter 
(33  1-3  cm)  is  the  most  practical.  At  this  point,  it  is 
well  to  test  the  power  of  convergence,  both  minus  and 
plus,  by  carrying  the  units  battery  down  (base  in)  to 
test  the  converging  power  in  the  act  of  accommodation. 
If  the  line  still  stays  single  to  the  end  of  the  battery 
(15°)  place  the  10°  or  15°  lens  on  "H"  with  base  in — then 
proceed  as  before  with  the  units  battery.  The  conver- 
gence should  be  25°  or  30°.  I  regard  this  test  better 
than  that  of  \  on  Graefe,  but  his  should  also  be  made. 
With  the  card  at  one-third  of  a  meter,  with  the  dot  line 
in  view,  put  the  10°  square  prism  on  "H"  base  down; 
this  doubles  the  card,  with  the  card  of  the  R.  E.  thrown 
up  above  the  other.  If  the  line  is  continuous  there  is 
no  insufficiency,  according  to  \  on  Graefe.  This,  how- 
ever, will  often  show  up  all  right  for  the  short  time  of 
examination,    under   the    stimulation   of   accommodation, 


164  HAZEN'S  NEW   FINDINGS 

but  on  examination  at  20  ft.  wc  often  find  that  patients 
cannot  adduct  5°,  showing  want  of  endurance,  and  that 
although  the  line  test  will  show  well,  yet  they  may  be 
suffering  from  asthenopia.  These  tests  unveil  a  large 
number  of  insufficiences,  that  are  easily  cured  by  mus- 
cular discipline.  This  test  is  very  much  neglected  in 
glass  fitting.  The  placing  of  a  convex  glass  removes, 
in  part,  the  accommodative  stimulus.  The  internal 
muscles,  having  had  the  habit  of  converging,  commen- 
surate with  the  accommodation  used,  now  lag  in  the  act 
of  convergence,  which  is  now  made  independent,  and  of 
which  there  is  as  much  required  as  before  glasses  were 
put  on.      (Fig.  1) 

This  is  a  common  trouble  in  administering  to  Pres- 
byopia. Although  the  lenses  are  right  ,the  muscles  are 
weak  and  the  spectacles  are  thought  to  be  wrong. 


166 


HAZEN'S   NEW    FINDINGS 


FIG.  1. 

(See  opposite  page  for  explanation) 


CONVEX  LENZES  167 

Fig.  1.  THE  EFFECT  OF  CONVEX  LENSES  ON  CONVER- 
GENCE. 

Lei  R.  R.  be  the  parallel  lines  which  the  axis  of  the  eyes  take 
on  looking  at  a  distance.  When  the  eyes  are  directed,  say  to 
P.  (the  reading  distance)  if  the  eyes  are  normal,  that  is,  have  accom- 
modation and  convergence  in  harmony,  convergence  accompanies 
accommodation  and  both  are  upon  the  object,  but  if  for  any  reason, 
glasses  are  put  on  to  aid  accommodation  to  enable  persons  to  see 
at  o  M.  A.  the  accommodation  is  aided  and  there  is  not  the  required 
focal  effort  made  to  see  at  a  near  point  as  before;  they  may  see 
to  read  with  one  eye  plainly,  or  for  a  short  time  with  both  eyes. 
but,  as  the  association  between  the  two  functions,  accommodation 
and  convergence  is  broken,  the  convergence  is  not  stimulated  as 
before,  and  the  visual  axes  of  the  eye-balls  stand  out  as  represented 
by  the  lines  C.  C.     The  object  then  is  doubled  or  indistinct. 

When  glasses  are  first  put  on  there  is  often  this  weakness  and  the 
muscles  have  to  be  disciplined  by  gradual  overcoming  the  new 
relation  or  a  system  of  gymnastics  must  be  provided  for  meeting 
the  condition. 

When  Presbyopia  is  gradually  met  by  frequent  increase  of  the 
convex  lens  as  it  developes,  the  convergence  is  disciplined  by 
effort  of  the  will  and  the  new  relation  is  met  and  no  great  incon- 
venience is  felt,  but  it  is  not  always  thus.  Asthenopia  may  be 
felt  and  sometimes  using  the  eyes  at  a  near  point,  has  to  be  aban- 
doned. 


168 


HAZBN'S  NEW   FINDINGS 


FIG.  2. 

(See  opposite  page  for  explanation" 


NAGEL'S   SYSTEM  ICO 

Fig.  2.     TO  DEMONSTRATE  NAGEL'S  SYSTEM  of  me- 

uring   convergence   and   its    relation   to   accommodation. 

Nagle  takes  one  metre  as  a  unit,  called  Metre  Angle,  which  cor- 
responds to  the  Metre  Lens  in  the  Dioptric  system,  which  we  have 
adopted  in  the  trial  case  of  which  Xagel  is  the  author. 

The  Metre  Angle  is  the  angle  formed  at  one  meter  distance  by 
the  intersection  of  the  visual  line  with  the  median  line. 

In  Fig.  2  let  the  pupillary  distance  P.  P.  be  the  base  line;  H. 
the  center  and  _M.  H.  the  median  line.  Inf.  will  be  the  direction 
of  the  optic  axis  (visual  line)  when  looking  at  a  distance  or  "In- 
finity." The  visual  lines  arc  then  parallel  to  the  medium  line 
M.  H.  Xow  let  the  eyes  lix  upon  an  object  at  1  Cone  metre). 
Then  the  deflection  of  the  axis  of  each  eye  to  1  with  P.  H.  forms 
the  angle  1  P.H.  and  it  is  the  metre  angle  of  deflection  or  conver- 
gence of  each  eye. 

At  2  or  50  C.  M.  it  is  2  M.  A.;  at  3  it  is  1-3  of  a  metre  angle  or 
3  M.  A.;  at  5  it  is  5.  M.  A.  This  system  applies  to  the  measure- 
ment of  accommodation  in  dioptres  and  at  those  points  it  is  repre- 
sented by  the  same  figures  but  designed  as  dioptres.  When  the 
measurement  is  taken  on  the  centermeter  scale  it  is  easily  reduced 
to  Xagel's  notation. 

The  lines  D.  D.  represent  divergence  and  are  measured  by  the 
system  of  Stevens  on  a  distant  object  and  are  negative  and  the 
angle  is  formed  by  carrying  it  to  a  point  which  would  be  behinf 
the  eyes  at  O. 

The  condition  of  the  visual  axes  of  main'  eyes  before  the  glasses 
are  prescribed  is  represented  by  the  lines   D.   D. 


170  HAZEN'S  NEW    FINDINGS 

Examination. 
The  Test  for  Muscular  Strength. 

Heretofore,  the  process  for  testing  the  capacity  of  the 
muscles,  has  been  to  put  such  prism  before  the  eye  as 
will  cause  diplopia,  and  ask  the  patient  to  fuse  the  divided 
light.  This  process  is  contrary  to  the  principles  of  mus- 
cular discipline.  The  modern  method  of  using  dumb 
bells  is  to  first  use  light  weights,  and  gradually  increase 
their  heft.  We  would  not  direct  the  jumping  of  a  canal 
to  discipline  the  leg  muscles.  \\  ith  this  method,  so 
long  used,  no  adequate  information  of  the  strength  of 
the  recti  is  obtained. 

The  appeal  to  the  muscles,  by  this  system,  is  so  radi- 
cally different,  that  it  changes  the  whole  aspect  of  the 
subject  of  muscular  discipline.  This  fact,  with  the  dif- 
ference we  make  in  the  adaptation  of  the  denomination 
of  the  lenses  to  the  particular  pair  we  wish  to  discipline, 
leads  us  to  affirm  that  muscular  discipline  of  the  eye 
muscles  has  not  been  adequately  tried.  The  quick 
response  to  the  improved  method  shows  this  to  be  true. 

The  particular  change  in  method,  which  we  use,  is 
to  pass,  in  succession,  the  prisms  from  a  low  denomination 
to  as  high  an  one  as  the  eyes  are  able  to  keep  fused,  and, 
when  the  eyes  cannot  hold  the  light  singly,  we  stop, 
for  that  last  prism  designates  the  strength  of  that  pair 
of  muscles. 

The  Internal  Recti. 

\\  ith  the  light  at  20  ft.,  commence  by  turning  a  5° 
prism  in  the  disk  over  the  L.  E.;  if  this  is  fuses,  turn  on 
the  10°;  if  this  is  also  fused,  go  on  until  one  is  turned 
on  that  will  cause  diplopia.  When  on-e  causes  double 
vision,  turn  back  to  the  one  that  can  be  fused,  and  then 
proceed  over  the  R.  E.  with  battery  thrusting  before 
it,  in  the  guide  (E)  the  1°,  and  carrying  it  up  until  the 


TESTING  STRENGTH  171 

light  parts.  This  measures  the  strength  of  that  pair. 
Care  is  to  be  taken  that  the  battery  is  run  smoothly 
for  a  hitch  or  accident,  that  jars,  will  cause  the  eyes 
to  let  go.  It  is  better,  at  the  first  sitting,  to  perform 
this  twice. 

Another  precaution  must  be  kept  in  mind.  These 
cases  have  so  schooled  themselves  as  not  to  take  notice 
of  objects,  moving  before  them,  and  they  will  allow  the 
light  to  part  and  one  object  to  pass  out  of  the  field  with- 
out noticing  it.  On  coming  to  the  end  of  the  battery, 
ask  them  to  take  notice,  as  you  quickly  jerk  up  the  bat- 
tery. The  eyes  are  in  position  to  cause  two  lights  to 
be  seen  for  an  instant,  if  they  have  fused  every  one. 
This  will  catch  their  dereliction. 

\\  ith  those  whose  muscles  are  sore,  the  parted  light 
will  fly  off  quickly,  and  there  will  be  no  movement 
toward  fusing  again,  while  with  others,  the  light  will 
sail  off  slowly,  and  still  others  will  suddenly  see  twc 
lights  and  not  see  them  part.  From  this  behavior, 
under  this  test,  much  can  be  learned  to  discipline  these 
muscles. 

It  is  found  that  very  often  a  patient  cannot  fuse  more 
than  a  5°  jump,  but  will  make  12°  to  15°  in  adduction  by 
adding  small  units,  showing  the  utility  of  at  least  a  15° 
battery  for  the  end  of  the  left,  and  demonstrating  that 
this  process  measures,  more  accurately,  the  strength 
of  the  muscles,  than  was  done  by  the  former  method. 
Then,  it  may  be  noted  that  the  muscles  will  act  more 
uniformly  and  do  better,  when  the}'  are  appealed  to  by 
regular   intervals,   with   a   slight  jump   between. 

The  standard  for  the  strength  of  the  internal  recti  should 
be,  at  least  25°  to  35°.  It  takes  23°  to  converge  to  reading 
distance,  but  I  have  seen  several  cases,  who  adducted 
35°  and  yet  suffered  from  use  of  eyes.  In  these  case-. 
it  takes  several  seconds  before  the  eyes  are  adjusted, 
so   that   quickness    and    facility    of    adjustment    of    the 


172  HAZKN'S   MOW    FINDINGS 

c\  cs  is  a  necessity  as  well  as  strength.  Some  of  these 
cases  have  a  history  of  great  discomfort,  and  have  been 
slower  to  gel  well.  Other  muscles  are  often  involved. 
\\  here  there  is  much  exophoria,  it  is  necessary  to  use 
the  slide  lenses  accompanying  the  instrument,  putting 
in  a  3°  or  5°  over  left  eye  with  base  in,  and  sometimes 
the  1°  over  the  R.  E.  in  addition,  in  the  phorometer 
slide  to  make  the  patient  see  through  the  eye  cups  and 
get  within  the  compass  of  the  instrument.  Of  course, 
the  denomination  of  these  must  be  included  in  the  problem . 

The  External  Recti. 

The  strength  of  these  muscles  is  found  by  the  use  of 
the  units'  battery  over  the  R.  E.,  carrying  it  down  with 
the  guide  (E)  with  base  in — abduction.  At  the  end, 
the  quarter  degree  battery  is  carried  in  horizontally 
on  the  lens  rest  "H,"  a  lens  at  a  time.  The  lenses  being 
placed,  base  up,  in  this  battery,  adds  at  the  end  of  the 
left,  a  1-4°  at  a  time  to  the  unit  battery  carried  in  the 
guide,  base  in.  The  standard  for  these  muscles  should 
be  at  least  5°  on  the  first  examination. 

The  Vertical  Muscles. 

These  muscles  are  examined  with  the  quarter  degree 
battery  over  the  R.  E.  Infraduction  is  done  by  carrying 
the  battery  up,  and  sursumduction  by  carrying  it  down. 

This  is  the  first  instrument  provided  with  a  quarter 
degree  battery.  In  treatment,  we  give  deflection  of  bat- 
ter}' to  increase  duction. 

The  Obltque  Muscles. 

The  measurement  of  the  strength  of  these  muscles 
alone  has  not  been  accomplished,  except  by  Steven's 
Clinoscope,    but    the    strength    of   those    associated    with 


TREATMENT  17:'> 

the  Superior  and  Inferior  Recti,  I  am  led  to  believe  can 
be  done  with  the  1-4°  battery,  carrying  it  up  or  down 
as  required  and  deflecting  it,  right  or  left,  to  the  angle 
necessary  to  get  into  the  line  of  action  of  the  two  muscles. 
The  degree  of  the  last  fused  lens  will  give  the  power, 
that  can  keep  the  light  fused  in  this  direction. 

I  have  not  had  sufficient  experience  with  this  condi- 
tion since  I  conceived  the  thought  to  fully  elucidate  this 
point. 

TREATMENT. 

The  treatment  consists  almost  entirely  of  gymnastic 
exercise.  Medicine  has  been  used  in  its  connection 
for  costiveness,  and  in  one  or  two  instances,  a  nerve 
tonic. 

The  refraction  is  looked  after,  but,  in  most  cases,  they 
have  been  in  the  hands  of  others  and  refracted,  and  as 
a  rule,  the  glasses  are  not  changed  until  after  the  gym- 
nastic treatment  has  been  finished. 

In  some  cases,  the  lenses  worn,  are  so  infinitesimal, 
that  it  is  recommended  to  lay  them  off;  as  a  general  rule, 
we  let  the  former  examination  stand,  and  allow  the  patient 
to  use  his  own  discretion,  whether  to  continue  wearing 
them  or  not.  In  the  majority  of  cases,  where  they  are 
wearing  under  +1.50s  D,  with  .50  D.  cylinder,  axis 
90°  or  180°,  they  have  taken  off  their  glasses  volun- 
tarily. In  some  cases,  on  first  examination,  the  glasses 
seemed  to  be  wrong,  but  exercise  of  the  muscles  was 
instituted,  and  correction  of  refraction  was  put  off  until 
the  end  of  treatment,  when,  after  such  muscular  exercise 
and  discipline,  the  glasses  proved  to  be  all  that  were 
needed. 

We  have  never  put  prisms  on  in  spectacles  over  any  of 
these  muscles  since  instituting  this  gymnastic  treatment, 
nor  have  we  seen  a  case  that  we  would  tenotomize,  except 
once,  and  in  that  case  the  vision  could  not  be  developed. 


174  HAZEN'S   NEW    FINDINGS 

Before  the  discovery  of  this  treatment,  I  performed 
tenotomy  and,  for  many  years,  frequently  performed 
the  operation  of  advancement. 

As  we  have  already  said,  the  treatment  of  the  extrinsic 
muscles  is  not  founded  on  the  phoria,  or  the  position, 
that  the  eyes  are  related  to  each  other,  (balance)  or  that 
the  object  in  the  treatment  of  them  is  to  correct  the  de- 
partures we  set  up  as  standards  of  position,  yet  the  phoria 
is  one  of  the  concomitants  of  the  disease,  and  should 
be  watched,  and  if  possible,  brought  to  that  position, 
where  there  is  the  least  expenditure  of  force  in  projection, 
to  do  the  work  of  functioning.  It  is  also  an  index  of 
some  indications  in  the  treatment.  It  leaves  the  eyes 
nearer  to  that  ideal  which  we  believe  Nature  would  seek 
to  maintain.  \\  e  therefore  measure  the  phoria  at  the 
beginning  of  every  sitting. 

We  always  discipline  the  muscles  with  the  object 
(light)  at  20  ft.  away,  free  from  the  element  of  accommo- 
dation. This  we  regard  as  important,  as  Dr.  Stevens'' 
conclusion  that  equilibrium  should  be  preserved  at  all 
points.  Von  Graefe,  he  says,  was  wrong  in  operating 
to  fit  the  eye  for  near  work,  and  throwing  it  out  of  balance 
for  distant  adjustment.  If  the  eyes  are  disciplined  on 
the  distant  point,  they  are  more  likely  to  come  into 
balance,  in  the  end,  for  all  points.  Experience  shows 
that  in  cases,  fully  disciplined  in  the  infinite  distant 
point,  the  eyes  are  fitted  for  all  points.  Then,  the  time 
in  which  the  eyes  are  brought  to  a  healthy  condition, 
in  this  method,  is  at  least  1-5  of  the  time,  given  in  any 
report,  made  by  those,  who  use  methods,  that  combine 
accommodation    and    convergence. 

We  treat  the  muscles  in  pairs,  and  do  not  know  of  any 
use  to  be  made  of  the  knowledge  of  one  muscle  of  the 
pair  being  stronger  or  weaker  than  its  fellow. 


ADDUCTION  175 

Adduction. 

The  pair  of  muscles  that  do  the  work  of  adduction  are 
the  muscles  that  modern  civilization  yokes  to  accomplish 
her  ambition  and  to  pile  up  the  fruits  of  industry.  No 
wonder  that  the  pace  man  has  set  for  these  muscles, 
should    tire,    produce    aches    and    at    last    a    break-down. 

They  are,  then,  the  principal  object  of  our  treatment 
in  muscular  affections.  The  standard  is  50°  and  it  is 
often  advisable  to  go  to  60°  or  "0°.  This  gives  a  reserve 
of  ability  that  lasts  for  years. 

\\  ith  judicious  treatment  by  the  Kratometer,  10° 
to  20°  of  exophoria  have  been  made  orthophoric  within 
a  month  and  amblyopia  has  been  relieved  and  useful 
vision   restored. 

The  use  of  the  "slide  lenses,"  as  directed  in  the  Exami- 
nation or  Test,  is  very  serviceable  and  indispensable 
in  high  degrees. 

The  exercise  of  these  muscles  should  be  guided  by  a 
good  deal  of  judgment.  There  are  some  patients,  who 
have  to  be  urged  and  taught  to  throw  the  will  into  the 
converging  act;  some  are  very  slow  and  will  allow  the 
light  to  go  apart  without  a  bit  of  evidence  of  using  the 
will.  Others  of  the  nervous,  quick  ambitious  type,  will 
overdo,  and  if  care  is  not  taken,  they  will  undo  all  the  good 
that  the  first  few  treatments  almost  invariably  show. 
From  five  to  seven  lifts  are  general!}'  all,  that  should  be 
given  at  a  sitting  once  a  day.  If  they  progress  very 
fast,  three  lifts  are  all  they  should  be  allowed  on  this 
pair. 

The  progress  of  exercise  is  much  the  same  as  described 
in  examination,  adding  5°  at  a  time,  turning  the  prism, 
in  the  disk,  onto  the  L.  E.  and  adding  the  square  lenses 
over  the  R.  H.,  which  I  generally  hold  between  my 
thumb   and   finger  on   the   rest    "H."     I   allow   a   rest  of 


176  HAZEN'S  NEW   FINDINGS 

a    few   seconds   after  each   lift.     The   slide   lenses   can   be 
used  if  it  is  desirable  to  go  above  60°. 

\t  the  beginning  of  the  treatment,  as  soon  as  the  light 
parts,  I  take  away  the  lenses,  but  as  progress  is  made, 
I  allow  the  patient  to  bring  back  the  parted  light,  and 
further  on,  1  urge  them  to  fuse.  There  is  but  one  degree 
to  correct  on  the  extrinsic  of  the  left  in  this  case. 

A  valuable  use  of  the  square  lenses  is  found  to  be  in 
climbing  to  higher  degrees  of  adduction.  \\  hen  a  second 
or  third  lens  in  the  disk  is  turned  on,  the  full  denomina- 
tion of  the  lens  has  to  be  corrected  on  fusing  it,  and  not 
the  difference  only  between  the  last  two.  W  hen  not 
able  to  correct  the  last  one,  instead  of  turning  back  to 
that  one  which  he  has  fused,  by  thrusting  the  5°  square 
lens  over  the  R.  E.  on  "H"  with  base  in,  the  patient  is 
enabled  to  fuse — then  withdrawing  this,  it  adds  5°  more 
— then  putting  it  back  with  base  out,  that  may  be  fused — 
then  go  on  with  the  battery  for  the  extreme  of  the  lift. 

Abduction. 

In  the  discipline  of  the  external  recti  the  units'  battery 
is  used  over  the  R.  E.  and  the  fractional  at  the  end  of 
the  lift.  Carry  the  unit  battery  down,  base  in,  until 
diplopia  is  produced,  then  go  back  to  the  lens  that  is 
fused,  and  thrust  in,  horizontally,  the  quarter  degree 
battery,  which  adds  1-4°;  if  that  is  fused,  add  1-2°  and 
so  on  to  1°.  If  the  pupillary  space  is  made  sufficient, 
there  is  room  for  the  four  lenses.  When  that  is  accom- 
plished, we  can  generally  drop  the  units  battery  another 
degree   and   then   proceed    as   before. 

Of  all  the  eye  muscles,  those  of  the  external  recti  are 
the  most  stubborn,  but  they  will  generally  yield.  More 
lifts  can  be  made  in  these  muscles,  at  a  sitting,  than  in 
any    other    pair.     The    standard    of    Dr.    Stevens    of    8° 


VERTICAL    MUSCLES  177 

for  abduction  is  to  be  sought,  but  6°  is  often  sufficient, 
and  even  5°  will  prove  to  be  all  that  is  necessary,  if  the 
other   muscles   are   doing   their   part. 

Verticals. 
Infraduction  and  Sursumduction. 

The  carrying  of  the  quarter  degree  (fractional)  with 
the  bases  of  the  lenses  up  over  the  R.  E.  or  down  over 
the  L.  E.,  we  term  Infraduction,  and  vice  versa  Sursum- 
duction. 

In  many  of  these  cases,  the  slide  lenses  are  serviceable 
in  assisting  the  eye  to  see  the  light  through  the  apertures 
in  the  cups.  \\  hen  the  L.  E.  turns  up,  the  base  of  the 
prism  should  be  down  over  that  eye  or  up  over  the  R.  E. 

Following  the  rule,  that  in  putting  a  prism  before 
the  eye  as  a  crutch,  the  base  should  be  toward  the  point 
to  which  the  eye  ought  to  turn,  and  in  putting  it  over 
the  fellow  eye  to  help  the  same  eye,  it  should  be  reversed, 
To  discipline  the  eye  to  action,  it  is  observed  the  apex 
is  in  the  direction  toward  which  the  eye  ought  to  turn. 

With  an  appeal  to  the  vertical  muscles  of  a  quarter 
degree  interval  of  prism,  the  muscles  respond  to  gym- 
nastic treatment  as  well  as  do  the  internal  recti  to  that 
of  one  degree  interval.  A  very  serviceable  way  to  make 
these  muscles  respond  is,  when — for  instance  Infraduction 
is  the  exercise,  on  going  up,  when  the  light  parts  and  the 
patient  cannot  fuse,  deflect  the  battery  tovard  the  median 
line  at  the  lower  end,  to  or  near  to  45D  until  the  lights 
are  fused  and  ask  the  patient  to  hold  them,  while  the 
battery  is  returned  to  90°  .  Often  another  quarter  can 
be  added  and  sometimes  a  full  degree  can  be  climbed 
at  one  sitting,  and  a  high  degree  of  hyperphoria  can 
be  corrected  in  one  month  or  less. 


l78  hazen's  new  findings 

Cycloduction. 

The  treatment  for  this  has  been  found  to  be  Infraduc- 
tion  and  Sursumduction.  The  cylinder  treatment  of  Dr. 
Savage,    has    not    proved   to   be   as   good,   in   my   hands. 

The  line  of  action  of  the  oblique  is  nearly  like  that 
of  the  verticals.  To  bring  into  action  the  oblique,  the 
treatment  under  Infraduction  and  Sursumduction  has 
been  found  to  be  effective,  and  Cyclophoria  has  dis- 
appeared. 

Red  Glass. 

The  Red  glass  is  kept  in  the  slide,  as  a  rule,  and  is 
in  situation  to  quickly  throw  it  before  the  L.  E.  as  occa- 
sion requires.  In  the  cases,  who  have  learned  to  sup- 
press the  image,  the  red  glass  is  often  very  serviceable. 
It  is  sometimes  better  that  the  red  glass  be  put  over  the 
best  visioned  eye. 

Fusing  Faculty. 

I  have  not  met  a  case  that  has  not  the  "fusing  faculty" 
unless  it  was  a  blind  eye.  It  is  sometimes  dull  but  I 
have  attributed  the  inaction  to  the  presence  of  Am- 
blyopia, or  to  the  indisposition  to  call  into  action  the 
muscles,  the  patient  having  acquired  the  habit  of  allowing 
things  to  happen  before  his  eyes  without  fixing  his  gaze 
upon  them.  Certain  cases,  who  have  had  several  treat- 
ments with  about  the  same  indifferent  results,  when 
they  have  been  urged  to  exert  their  will  power  and  hold 
the  fusing  of  the  lights,  have  seemed  to  awaken  to  a  new 
idea    and   have   brought   this   fusion   faculty   into   action. 

The  successful  treatment  of  these  cases  is  not  so  simple 
a  matter  as  one  might  suppose  from  reading  this  de- 
scription of  the  process. 

The  important  difference  in  these  cases  is  not  in  the 
imbalance,  neither  is  it  in  the  lifting  power  of  the  muscle, 


UNNECESSARY  GLASS  FITTING  179 

but  in  the  classification  of  the  weakness  of  the  apparatus 
of  this  function.  It  is  found  in  the  nervous  temperament 
and  constitutional  make-up  of  the  individual.  Some 
have  nerves  like  wire,  that  do  not  feel  anything,  when 
you  know  that  the  same  amount  of  irritation  would 
put  others  to  bed.  Oculists  know  this  to  be  true.  One 
man,  with  ulceration  of  the  cornea,  will  not  acknowledge 
pain,  even  when  there  are  ulcerative  abrasions,  the  size 
of  a  half  pea;  another,  with  a  much  less  dangerous  con- 
dition, will  not  leave  his  bed.  So  it  is  in  the  ocular 
muscles.  A  man  may  have  a  high  degree  of  hyper- 
phoria, and  although  he  uses  both  eyes  in  reading  and 
expends  a  vast  amount  of  nervous  force  in  adjustment, 
there  is  no  complaint  of  pain,  and  he  only  drops  to  sleep 
in  a  few  minutes. 

Another  has  sufficient  nervous  vitality  to  correct  an 
exophoria  but  irritation  is  not  reflected  on  systemic 
nerves.  The  power  of  resistance  is  so  effective  that 
the  only  inconvenience  is  weariness  on  near  work. 

GLASS    FITTING    CRAZE 

The  author  of  this  system  is  well  aware  of  the  antag- 
onism he  produces,  in  some  quarters,  to  the  extensive 
craze  of  fitting  lenses  for  every  symptom  of  discomfort 
from  use  of  the  eyes.  He  believes  that  the  majority 
of  young  people,  who  are  wearing  lenses  (spherical, 
cylinders  and  prisms)  have  merely  had  a  splint  or  crutch 
adjusted,  which  supports  or  props  up  and  puts  at  rest  a 
condition,  that  should  be  met  by  a  different  method  of 
treatment,  and  this  conviction  comes,  not  from  theory 
but  from  practical  experience  and  observation.  In  this 
category  he  would  make  exception  in  high  degrees  of 
Ametropia,  which  are  deformities,  and  need  braces, 
and  of  course,  also  that  condition  of  Presbyopia,  which 
necessitates  glasses  for  all,  when  the  time  comes. 


1*"  HA/K.VS    XKW    FINDINGS 

After  fifteen  years'  practice  of  this  system,  and  having 
practiced  the  old  method  twice  this  length  of  time,  and 
after  making  a  faithful  study  of  the  progress  in  the  man- 
agement of  the  Function  of  Vision,  in  the  hands  of  his 
predecessors  for  half  a  century;  and  knowing  the  claims 
of  the  disciples  of  Donders,  regarding  refraction;  and 
fully  appreciating  the  great  improvement  Donders  has 
made,  toward  the  solution  in  the  immense  field  of  dis- 
orders of  the  function  of  vision — it  must  be  acknowledged 
that  "New  Findings"  has  a  narrow  margin  of  nezv  prin- 
ciples, but  the  application  of  the  principles  already 
known,  and  the  findings  of  new  applications,  with  some 
variation  in  appliances,  are  achievements  which  are 
gratifying — especially,  when  these  new  applications  are 
responded  to  quickly  and  satisfactorily  in  a  large  number 
of  cases  formerly  passed  by.  They  also  open  new  avenues, 
which  the  Ophthalmologist  has  not  supposed  belonged 
to  his  branch;  symptoms  that  are  pronounced  strange 
and  which  go  unlabeled  and  unexplained.  While  the 
difference  in  and  additions  to  the  mechanism  seem  small, 
the  success  of  the  adaption  to  the  end  is  marvelously 
great. 

Thus  we  see  that  "New  Findings"  is  but  the  adapta- 
tion and  application  of  the  old  and  well  known  principles 
in  physical  development;  that  exercise,  discipline  and 
work  are  the  right  means  for  bringing  into  health  and 
use,  any  and  all  functions  of  the  physical  organism; 
that  to  attain  a  high  degree  of  perfection  in  the  physical, 
mental  and  even  the  moral  system,  or  attain  to  the  best 
possibilities  of  the  human  functions,  zvork  and  incessant 
toil  are  necessary,  and  not  rest;  that  to  keep  these  functions 
in  repair,  and  give  them  long  life,  and  enable  them  to 
reach  towrard  a  still  higher  point  of  conception,  can  be 
done   only   by   continued    effort   and    strenuous    activity. 

This  system  of  gymnastic  treatment  of  the  eye,  which 
I  have  found  practical  for  fifteen  years,  and  have  attemp- 


FIELD  OF  APPLICATION  18 

ted  to  describe  in  these  papers,  opens  up  a  successful 
and  effective  treatment  of  certain  forms  of  eyestrain, 
which  have  been  so  easy  of  management  in  my  own  hands 
and  those  of  others  who  have  tried  it,  that  the  success 
has  been  a  continual  surprise  and  wonder. 

We  are  constantly  meeting  with  cases  in  whom  there 
has  been  no  suspicion  of  asthenopic  symptoms,  and  who 
have  made  quick  recovery  with  this  exercise.  Many 
cases,  classified  under  the  head  of  nervous  and  non- 
organic, have  been  permanently  relieved  or  greatly 
benefitted.  Not  only  has  it  been  applied  with  much 
quicker  and  surer  results,  in  those  cases  of  the  lateral 
muscles,  already  recognized  as  muscular  forms  of  eye 
strain,  but  it  has  effectively  taken  hold  of  those  most 
puzzling  cases  of  the  verticals,  and,  with  equal  facility, 
conquered  these  in  which  there  was  formerly  no  success, 
and  has  shown  that  these  muscles  belong  to  the  general 
lrws  governing  orthoptic  treatment  of  eye  muscles  and 
are   equally   susceptible   to   it. 

Again,  there  is  a  high  percentage  of  cases,  which 
have  been  lost  to  Ophthalmologists,  by  being  relegated 
to  other  specialists  for  constitutional  treatment  and  pro- 
longed rest,  and  were  cut  out  of  the  industrial  world 
for  a  time,  or  permanently,  who  have  been  restored 
to  active  usefulness,  within  a  month,  by  this  treatment. 

Indeed,  I  predict  that,  when  due  attention  is  paid  to 
"Muscular  Eye  Strain,"  according  to  the  idea  of  "New 
Findings,"  it  will  be  found  to  occupy  as  conspicuous 
a  place  in  Ophthalmology  as  does  that  of  its  twin  sister 
"Refraction." 


EXAMINATION  OF  EYE  MUSCLES 
OF  502  CHILDREN 

IN   THE 

DES  MOINES  SCHOOLS 

From   Fifth   to   Eighth  Grade,  Age  10  to  12  years. 


The  pupils  were  designated  by  number.  The  age 
and  whether  or  nor  they  were  troubled  with  their  eyes 
was  ascertained  by  questioning;  and  if  any  discomfort 
their  symptoms  were  noted  briefly.  The  vision  was 
taken  of  each  eye  singly,  and  then  the  balance.  The 
common  method  of  using  a  prism  (square)  was  used, 
free  from  the  instrument  to  see  what  prism  could  be 
corrected  in  adduction.  The  test  was  then  made  by  the 
Maddox  rod  for  lateral  and  then  vertical  deviation. 
The  number  of  inches  was  noticed  on  the  cross-bar 
as  suggested  by  Maddox,  and  the  deviation  was  measured, 
also  by  the  prism.  Care  was  taken  to  have  the  aperture 
through  which  the  candle  shone,  at  twenty  feet  distant, 
but  half  an  inch  in  diameter  to  get  the  hyperphoria, 
and  a  1-4°  was  noted.  There  was  no  consonance  between 
the  number  of  inches  on  the  cross-bar,  either  lateral 
or  vertical,  to  what  was  found  by  the  prism.  It  sometimes 
differed  widely.  Fifty-six  of  the  cases  had  hyperphoria 
of  this  amount  but  in  my  tables  I  do  not  use  this  amount 
in  casting  up  the  percentage  of  hyperphoria,  so  that  I 
might  conform  to  the  reports  of  other  observers.  These 
tests  were  also  made  by  the  Maddox  double  prism  for 
heterophoria,  at  16  inches  distance;  the  double  prism 
also  for  cyclophoria;  then  Yon  Graefe's  test  at  16  inches 
with  base  down  looking  at  a  dot  with  line  drawn  verti- 
cally through  it.  In  high  degrees  of  heterophoria,  the 
red  glass  is  used  over  one  eye.  The  duction  power: 
adduction,  abduction  and  sursumduction — carrying  the 
battery  over  the  right  eye  was  then  taken,  one  right  after 
the  other. 

Of  the  502  examined,  there  were  those  with  one  blind 
eye,  strabismus,  and  dummies,  making  12  cases  deducted 


1S»;  HAZEN'S   NEW    FINDINGS 

from  502,  which  leaves  490  from  which  I  compute  my 
statistics.  Of  these,  half  were  boys  and  half  girls.  Two 
hundred  and  forty  one,  49  per  cent  of  the  number  claimed 
they  had  no  trouble  with  their  eyes,  and  249  had  more 
or  less  "hurt"-— 51  per  cent.  Twenty-seven  more  said 
at  first  they  had  no  trouble,  but  on  questioning  them 
further  admitted  that  they  had  had  headache,  but  did 
not  attribute  the  symptoms  to  any  connection  with  their 
eyes.  Of  the  two  hundred  and  forty  nine  cases,  50  per 
cent  had  symptoms  of  headache — forehead,  temples  and 
back  of  head  —  eye  ache,  dizziness,  watering,  blurring, 
double  vision,  smarting  and  hurting  on  use  of  eyes.  Of 
the  four  hundred  and  ninety,  sixty  had  vision  below 
standard.  A  few  of  these  had  vision  in  one  eye  20 /xx. 
There  were  28  wearing  glasses;  25  had  worn  glasses  but 
had  discarded  them. 

The  refraction  was  not  corrected  before  the  examination 
of  the  muscles  was  made.  The  balance  and  strength  of 
the  muscles  was  the  object,  aside  from  the  cause.  The 
tables  herewith  will  give  further  results  of  this  examination. 


TABLE-SCHOOL  EX  A  MI  NATION  187 


TABLE  NO.  1  SHOWING  THE— PHORIA. 


ESOPHORIA 

EXOPHORIA 

HYPERPHORIA 

RECAPITULATION 

DEC 

NO. 

DEC 

NO. 

DEC 

NO. 

LATERAL 

XA  67 

K 

37 

X 

41 

Orthophoria      96 

19% 

1 

68 

l 

42 

X 

21 

Esophoria        288 

59% 

2 

42 

2 

12 

1 

12 

Exophoria        106 

22% 

3 

37 

3 

6 

IK 

5 

•1 

30 

4 

5 

l# 

5 

490 

100% 

5 

11 

5 

1 

1M 

2 

VERTICAL 

6 

9 

6 

1 

2 

1 

Orthophoria    343 

70% 

3 
6 

8 
9 

1 

1 

2K 
3 

2 

1 

l/i  Hyper'a        56 

11% 

8 

399 

9 

10 
11 

3 

1 
o 

12 

1 

3^ 

1 

K  Hyp  &  ovr  91 

19% 

106 

91 

490 

100% 

12 

4 

22% 

20% 

13 

1 

15 

1 

19 

1 

Orthophoria 

96 

20 

1 

19% 

25 

1 

288 
59% 

iss  HAZEN'S  NEW   FINDINGS 

At  the  risk  of  repetition  of  thought,  I  must,  in  closing 
this  dissertation  on  Eye  strain,  again  call  special  attention 
to  this  subject  and  endeavor  to  impress  its  importance 
and  universality,  and  show  up  the  findings  that  have 
been  made,  which  have  hitherto  been  entirely  missed, 
passed   over,    ignored   or   repudiated    by   the   profession. 

Alan's  insight  into  the  ailments  of  humanity  is  very 
limited  and  his  knowledge  is  hampered  by  his  precon- 
ceptions, his  training,  his  prejudices  and  his  self  interest. 
He  is  puffed  up  with  learning  and  position;  he  is  schooled 
into  doctrines  and  modes  of  thought;  he  casts  aside 
propositions  that  are  not  dressed  in  the  fashions  of  the 
day;  he  weighs  the  movement  of  confreres  in  the  light 
of  self  interest  and  avariciousness.  A  new  theory,  how- 
ever brilliant  and  genuine,  has  to  undergo  the  innuendoes 
of  men,  who  should  be  the  first  to  interest  themselves 
in  its  investigation  and  promotion. 

The  history  of  Asthenopia  has  its  moral  and  social 
aspects,  which  have  not  been  pictured  in  this  book. 
Men,  who  have  contributed  largely  to  its  development, 
have  "suffered  the  slings  and  arrows  of  outrageous  for- 
tune," and  have  been  ostracized  by  their  brethren  in 
consequence.  But  the  penalty  of  radical  ideas  in  this 
limited  field  of  medicine,  is  the  same  as  in  the  other  walks 
of  life — martyrdom,  in  different  degrees  of  severity, 
is  always  meted  out  in  proportion  to  the  angle  in  which 
it  deflects  the  needle  of  the  staid  thought  of  the  times, 
and  hurts  in  proportion  to  the  size  of  the  angle  of  current 
opinion. 

The  system  of  the  Kratometer,  which  administers  to 
the  muscular  cause  of  eye  strain,  is  new  in  many  respects 
and  differs  from  that  heretofore  practiced.  It  has  for 
its  principle  basis  much  that  has  been  previously  worked 
out  by  others,  and  the  modifications,  which  it  institutes 
seem  to  be  not  very  radical,  but  its  adaption  to  the  con- 


EYE  STRAIN  180 

ditions  of  this  particular  form  of  Asthenopia  is  astonishing 
to  those  who  learn  to  apply  it. 

There  is  a  certain  percentage  of  weak  convergence 
and  hyperemic  conditions  that  responds  quickly  to  the 
treatment  ;xu'i  the  result  is  satisfactory  and  delightful, 
but  there  are  in  every  community  those,  suffering  from 
the  reflex  symptoms  of  eye  strain,  which  produce  the 
secondary  symptoms,  which  are  finally  taken  up  as  the 
primary  disease,  and  treated  as  a  distinct  disease,  and  the 
first  cause,  the  eye  strain,  is  forgotten.  These  patients 
first  try  the  oculists  or  other  men  who  adjust  glasses, 
and  most  of  them  have  some  inkling  of  the  association 
of  the  lextrinsic  muscular  system  (adjustment)  of  the 
eye  with  the  refractive  part  of  the  function  of  vision, 
but  as  a  general  thing  it  is  entirely  neglected  or  sup- 
posed to  be  but  little  involved.  The  parties,  getting 
but  little  or  no  relief,  try  again  and  search  for  the  one 
of  highest  reputation  as  a  dernier  resort,  and  from  him 
they  get  their  ultimatum  in  his  specialty.  Unless  the 
Asthenopia  is  accommodative  entirely,  they  get  no  sat- 
isfaction and  gradually  come  to  the  conclusion  that  they 
are  invalids  and  have  some  constitutional  disease  and 
proceed  to  the  mummyfication  of  themselves.  They  may 
have  been  advised  by  their  Dernier,  to  quit  work  for  six 
months  to  recuperate  their  health. 

This,  to  many,  is  too  much  of  a  doxology  to  their  hopes 
and  aspirations,  and  they  resolve  to  consult  some  Nervous 
Disease  man,  for  their  symptoms  are  so  distressing  and 
unbearable  that  they  are  willing  to  do  anything  to  rid 
themselves  of  this  incubus.  If  the  tangent,  which  the 
reflex  has  taken,  be  neuralgic,  analgesic  remedies  are 
administered;  if  mental,  rest  at  some  Sanitarium  with  a 
watchful  nurse  is  recommended;  if  the  pneumogastric 
nerve  plays  havoc  with  the  digestive  apparatus,  a  course 
of   diet,    baths,    electricity    and    massage    are    prescribed. 


190  MAZKX'S   N'KW    FINDINGS 

There  is  a  high  percentage  of  these  cases  that  are 
asthenopic,  and  have  their  first  cause  in  Eye  strain,  and 
a  majority  of  them  are  ocular  motor,  which  get  different 
classifications,  such  as,  neurasthenia,  nervous  pros- 
tration, psychosis,  brain-fag,  nervousness,  hysteria,  chorea, 
insomnia,  epilepsy.  These  are  classifications  of  symptoms 
merely;  they  are  not  organic  and  when  the  first  cause  is 
removed  the  patient  is  well. 

The  professional  gap  between  the  Oculist  and  the  Ner- 
vous Disease  man  is  a  wide  one.  They  have  as  little 
interchange  of  thought  or  consultation  as  two  denom- 
inations in  the  ecclesiastical  world.  The  human  system 
has  a  number  of  tabulated  symptoms  that  arise  from  the 
anomalies  of  the  extrinsic  muscles,  which  probably  both 
the  Oculist  and  the  Nervous  Disease  man  had  oppor- 
tunity to  handle,  but  neither  has  put  his  finger  on  the 
cause  and  does  not  effect  a  cure  because  of  this  fact. 
Occasionally  some  relief  has  been  effected  by  withdrawing 
the  use  of  the  eyes  from  labor,  and  the  general  health 
has  improved  and  maybe  by  such  process  they  have  been 
relieved  for  a  short  time,  but  a  return  to  the  same  labor 
will  bring  about  like  results,  for  the  cause  is  not  removed. 

Patients  have  been  under  my  treatment,  who  have  been 
glassed  by  different  men  from  four  to  fifteen  times,  and 
who  have  also  consulted  Nervous  Disease  men,  and  in 
some  cases  both  specialists,  failing  to  find  a  cause  for 
the  symptoms  described,  have  attempted  to  convince 
the  patients  that  there  was  no  cause  for  their  nervousness 
and  morbid  fears,  and  that  there  was  no  occasion  for  their 
anxiety  that  if  they  would  summon  their  will  power, 
they  could  throw  off  their  nervousness;  or  that  if  they 
would  take  their  minds  off  themselves  and  forget  their 
ailments  they  would  overcome  or  master  the  imaginary 
ills. 

These  people  are  real  sufferers.  It  is  sometimes  psychi- 
cal; in  others  abdominal;  in  others  neuralgic;  sometimes 


CASES  L9J 

attributed  to  billiousness,  dyspepsia,  or  some  consti- 
tutional breaking  down  or  want  of  rest.  Whereas  all 
these  are  the  effects  of  reflex  symptoms  of  eye  strain. 
These  patients  get  no  sympathy  from  their  friends.  It 
is  often  that  the  manifestation  is  such  that  the  patient 
is  the  only  one  to  whom  the  phenomena  are  a  reality, 
and  he  learns  to  endure  his  ills  with  as  much  equanimity 
as  he  can  command. 

In  the  meantime,  much  suffering  abounds  in  every 
community,  and  those  who  are  expected  to  treat  these 
afflictions,  are  failing  to  discover  that  eye  strain  is  very 
closely  related  to  many  forms  of  Nervous  disorder.  When 
it  is  once  recognized  that  the  reflex  effect  of  Eye  strain 
upon  the  general  nervous  system  is  very  severe  and  wide 
reaching;  when  those,  who  make  a  specialty  of  ministering 
to  nervous  debility,  accept  this  as  the  real  situation, 
then  they  will  join  hands  with  the  Oculist  in  investigating 
this  new  field,  and  much  good  will  be  accomplished- — 
through  their  united  efforts. 

CASES. 

Case  1.  August,  1896,  Miss  M.  B.,  Indianola.  Student.  Age 
about  20  years.  Deficient  in  constitutional  tone.  I  had  corrected 
refraction  but  on  returning  to  study  had  trouble  again;  pain  of  a 
smarting  lancinating  character.  Orthophoric.  Adduction  19°; 
abduction  8.  Having  exhausted  my  knowledge  on  this  case,  I 
sent  her  to  Chicago  to  Dr.  Holmes,  who  found  nothing  to  do  but 
to  give  gymnastic  exercise  on  the  internal  recti.  The  endeavor 
to  carry  out  this  instruction  resulted  in  the  first  steps  of  this  treat- 
ment. In  fifteen  treatments  I  brought  the  recti  to  the  standard, 
50°,  and  discharged  her.  She  remained  free  from  the  trouble  and 
was  able  to  prosecute  her  studies  moderately. 

Case  2.  November  1896,  High  school  student.  Had  trouble 
with  eyes  since  going  to  kindergarten;  remains  for  hours  at  a  time 
in  a  dark  room;  intolerance  of  light,  especially  artificial  light; 
headache  about  the  eyes,  could  get  relief  with  hot  applications. 
She  wore  weak  cylinders.  Vision  good,  but  found  it  difficult  to  get 
clear    vision    because    of    blurring    or    double    vision.      Esophoria. 


1!»:  HAZEN'S   NEW    FINDINGS 

2  1-2*  .Adduction  20°.  Removed  glasses.  Treatment.  Adduc- 
tion, 23  treatments,  when  the  esophoria  was  1  1-2°.  Remained  in 
school  while  treating,  and  improved  from  the  start.  January, 
L901,  lias  been  free  from  pain,  and  only  on  intemperate  use  exper- 
ience- inconvenience.  Has  not  worn  glasses  since,  and  has  no 
trouble   whatever. 

Case  3.  January,  1897.  W.  G.  R.  Connected  with  a  news- 
paper and  member  of  the  Legislature.  I  had  fitted  him  with  glasses 
under  a  cycloplegia,  but  he  was  not  relieved  For  seven  years 
he  had  not  been  able  to  use  his  eyes  in  the  evening.  In  the  daytime 
could  use  them  but  two  hours,  thirty  minutes  at  a  time  at  the  most. 
Eyes  smarting  and  itching  and  headache.  Esophoria,  2°,  adduc- 
tion 5°.  In  32  treatments  adduction  50°.  He  used  his  eyes  that 
winter  night  and  day  as  any  other  member  of  the  Legislature. 
In  the  winter  of  1898,  he  continued  well.  He  is  now  the  proof- 
reader in  a  large  establishment. 

Case  4.  February,  1897.  Mrs.  J.  B.  D.,  age  about  30.  Had 
an  attack  of  i  ritis  in  right  eye  three  years  before,  which  left  eyes 
weak.  Had  been  under  good  physicians  and  two  oculists.  Vision 
good.  Severe  lancinating  pains  and  feelings  of  eye-balls  being 
drawn  back,  especially  at  night.  On  waking  in  the  morning  was 
obliged  to  rub  eyes.  Unable  to  use  eyes  with  any  comfort.  Es- 
ophoria, 10°,  adduction  35°.  Treatment,  adduction.  In  22  treat- 
ments was  relieved  entirely.  The  winter  of  1898  had  Lagrippe 
which  seemed  to  affect  eyes  somewhat,  but  did  not  relapse  and  re- 
mains well.      The  10°  of  esophoria  remains  in  this  case. 

Case  5.  May,  1899.  W.  H.  W.  Age  about  42.  Travelling 
man.  Good  constitution  and  physique;  had  had  neuralgia  in  and 
about  the  eyes  for  15  years.  Unable  to  use  eyes  at  near  work. 
Deprived  entirely  of  reading  on  the  cars.  Consulted  an  eminenz 
oculist  in  Boston,  and  was  wearing  a  prism  prescribed  by  him, 
which  availed  nothing.  Examination  showed  he  was  emmetropic. 
Orthophoric.  Adduction  only  5°.  I  gave  him  the  Kratometric 
treatment  on  adduction  daily  when  in  the  city,  which  was  broken 
into  sometimes  for  long  intervals  and  it  extended  to  September, 
30  treatments  in  all.  After  the  fifth  treatment  he  had  no  more 
neuralgia,  and  it  never  returned.  Heterophoria  was  developed — 
first  exophoria,  and  then  esophoria. 

He  died  from  Bright's  diseaes,  August  2,  1904,  but  had  no  return 
of  eye  trouble. 

Case  6.  May  25th.,  1897.  Dr.  S.,  age  about  35.  Addicted  to 
much  reading;  for  three  or  four  years  had  been  troubled  with 


CASKS  193 

ness  of  eyes  on  reading;  eyes  hot  and  dry,  feeling  of  sand  under  the 
lids,  which  would  grow  worse  if  reading  was  continued,  artd  the 
letters  would  dance  and  become  blurred,  when  in  a  short  time, 
he  would  be  unable  to  open  his  eyes.  The  swollen  condition 
showed  itself  under  the  eyes,  like  the  condition  often  attributed  to 
disease  of  kidneys.  Emmetropic  esophoria,  2°;  adduction  5°; 
Kratometric  treatment  of  the  adductors  resulted  in  attaining  50° 
in  25  treatments,  when  all  disagreeable  symptoms  were  removed, 
and  he  has  had  no  return  of  the  trouble  since.  In  this  case,  as  in 
many,   the   heterophoria   increased. 

Case  7.  Miss  S.  M.,  Brooklyn,  Iowa.  Age  23.  Graduated 
from  high  school  with  difficulty,  having  trouble  for  about  eight 
years.  Tried  college  work  and  teaching,  but  had  to  give  them 
up,  and  for  two  years  had  hardly  been  able  to  read  a  newspaper 
the  length  of  a  finger.  Had  been  fitted  and  refitted  by  different 
oculists;  the  last  one  put  on  plain  glasses.  She  was  in  fairly  good 
health.  She  had  nearly  all  the  symptoms  of  asthenopia  given 
under  this  head.  She  was  unable  to  look  up,  or  at  any  moving 
object  without  immediately  closing  her  eyes.  Her  manner  had 
become  stiff  and  eyes  red,  dull  and  without  animation.  Emme- 
tropic. Orthophoric.  Adduction  34°;  abduction  9°;  sursumduc- 
tion  1-4°  Treatment  consisted  in  the  duction  of  every  muscle  in 
the  orbit.  Adduction  attained  65°;  abduction  15°;  sursumduction 
3  3-4°. 

By  Christmas  she  was  free  from  pain,  attended  the  theatre  with- 
out i neon venience  and  in  the  next  three  months  read  several  books 
without  return  of  symptoms  to  any  great  extent.  This  case  puzzled 
me  under  my  own  theories  and  I  could  get  no  satisfaction  in  the 
theories  of  the  books.  The  development  of  a  high  standard  of 
strength  of  the  muscles  seemed  the  only  treatment  indicated.  Ex- 
amined eyes  for  error  of  refraction  under  a  cycloplegia  (atropia) 
and  found  -4-   :50  hypermetropia.     Glasses  not  recommended. 

Case  8.  October  9th.,  1902.  J.  C.  Lohrville,  Iowa.  Age  14 
years.  Had  been  fitted  with  glasses  four  years  before.  The  pre- 
sent trouble  commenced  in  January  1902.  Pain  in  the  eye-balls. 
Relief  on  pressure  of  the  eyes.  Exophoria  3°;  adduction  6°;  ab- 
duction 8  .  In  twenty  treatments  taken  in  ten  days,  attained 
adduction  of  60°.  Esophoria  10°  on  conclusion  of  treatment. 
She  returned  home  and  at  once  resumed  her  studies  and  remains 
well. 

Case  9.  December  20th.,  1902.  Miss  X.  L.  H.,  teacher.  Been 
troubled   five  or  six  years.      Constitution  good.      Been   fitted   plain 


194  HAZEN'S   NEW    FINDINGS 

and  bold  to  persist  in  wearing  them.  Inability  to  fix  eye 
on  object;  sensation  of  drawing  eyes  backward;  nervous,  sleepless; 
eyes  watering  on  use;  pain  in  balls  of  eyes,  shooting  through;  pain 
on  top  of  head,  back  and  in  shoulders.  Relief  on  pressure  of  eye 
balls.  Esophoria,  1°;  adduction,  17°;  abduction,  6°.  Twenty 
three  treatments.  Adducted,  70°.  Took  set  of  four  prisms  to 
practice  at  home.  Has  been  free  from  pain  ever  since,  and  is  in 
much   better  health  and  spirits. 

Case  10.  March  24th.  ,1903.  F.  W. — Electric  lineman,  inside 
work;  age  about  25  years.  Had  been  under  treatment  of  general 
practitioner  for  several  months  for  headache,  back  and  front.  For 
eight  weeks  it  became  so  severe  he  had  to  stop  work  although  it 
was  the  busy  season.  Could  not  stand  on  a  ladder  and  ,when  stoop- 
ing, black  objects  came  before  his  eyes.  His  eyes  had  that  dull 
look,  as  if  moving  the  ball  was  painful.  He  had  no  suspicion 
that  his  eyes  were  defective.  He  was  sent  to  me  by  his  physician 
to  see  if  there  was  not  some  eye  affection.  Vision  /xx.  Emme- 
tropic. Exophoria,  °1.  No  hyperophoria.  Adduction,  12°;  ab- 
duction, 7°;  sursumduction,  2  3-4°.  Treatment,  adduction.  After 
fifth  treatment,  there  was  no  more  pain  in  the  back  of  the  head. 
When  he  reached  adduction  30°,  he  went  to  work  and  lost  no  more 
time.  In  fifteen  treatments,  he  reached  50°  and,  after  twenty  two 
treatments,  was  pronounced  cured.  He  still  remains  well.  He 
showed  esophoria  after  a  few  treatments,  and  quit  at  1-2°  of  esophoria 

Case  11.  Dr.  H.,  Dentist.  Age  about  thirty  years.  Wore 
glasses  when  a  boy  but  not  in  late  years.  Had  attacks  of  sudden 
blindness.  Once  while  playing  in  an  orchestra  fell  off  his  chair; 
was  carried  home,  put  to  bed  and  treated  for  billiousness;  there  were 
but  few  untoward  symptoms;  some  blurring,  and  a  hot  feeling  of 
the  eyes  and  pain  in  temple,  but  he  was  generally  able  to  attend  to 
his  practice.      His  physique   was  extra  good. 

Emmetropic  (manifest)  vision  20/xx — Orthophoria  of  all  the 
muscles — adduction  12°  to  15°;  abduction  6°.  He  attained  50° 
adduction  in  6  treatments.  In  twenty-two  treatments  he  was  pro- 
nounced cured.  The  sysmptoms  did  not  return,  and  the  two  sub- 
sequent months,   he  was   found   to   maintain  50°  adduction. 

Case  12.  July  22.  1904.  Age  50  years.  Architect.  Had 
been  fitted  by  four  or  five  oculists,  in  this  city  and  Philadelphia. 
The  results  of  these  examinations  were  about  the  same,  -J- 1.50. 
Very  nervous  on  using  eyes;  watering  of  eyes;  swelling  about  eyes; 
dull  drowsy  look;  dizziness;  stomach  affected;  sickness  at  and  before 
meals;    costiveness;    pain    in    eyeballs,    especially    in    the    morning, 


CASKS  195 

also  in  temples.  Fingered  and  pressed  on  eyeballs  a  good  deal. 
About  to  give  up  profession.  Could  not  go  up  onto  buildings, 
and  drafting  became  almost  impossible. 

My  examination  of  the  refraction  showed  about  the  same  results 
as  found  by  others.  There  was  a  spasm  of  muscles  and  examination 
was  not  satisfactory. 

Orthophoria  of  both  laterals  and  verticals.  Could  jump  15° 
but  was  slow  to  adjust  when  taken  away.  The  exercise  caused 
sickness  of  the  stomach,  whenever  the  highest  number  he  could 
attain  was  reached.  The  light  would  grow  dim  but  after  five  or  six 
treatments,  the  light  became  clearer  and  vision  on  the  street  im- 
proved. In  20  treatments  he  found  that  his  digestion  had  greatly 
improved,  and  costiveness,  for  which  he  had  been  treated  by  several 
physicians,  was  relieved  without  medicine.  Appetite  so  much  im- 
proved that  he  was  apt  to  overeat. 

The  esophoria  increased  under  treatment  which  was  mostly 
adduction,  to  14°,    but  the  adduction  was  uniform  in  its  progress. 

At  the  end  of  the  treatment,  there  still  remained  a  difficulty  in 
his  drafting;  the  side  of  the  sheet  would  seem  to  turn  up  and  form 
a  hollow  curve  of  the  sheet.  O.  D.  Astigmatism  of  -j~  .50  was  found 
at  an  axis  of  10°  out  of  the  vertical.  These  glasses,  with  pres- 
byopic addition,  were  ample  to  make  him  efficient  in  his  severe 
labors  in  this  very  arduous  occupation,  and  the  standard  has  been 
maintained  to  the  present  time  without  difficulty. 

Case  13.  August  4th.,  1904.  Miss  J.  J.  M.,  age  34.  House- 
work and  china  painting.  Had  been  fitted  under  atropia,  R.  and 
L.  -f-  1.00.  +  -50  at  180°V  20 /xx.  Sleeplessness  on  using  eyes. 
Car  sickness.  Pain  lancinating  in  balls.  Relief  on  pressure. 
Had  been  troubled  for  two  years,  and  for  one  and  a  half  years  had 
given  up  painting.  Esophoria  4°  verticals  orthophoric.  Adduction 
23°,  abduction  7°.  Improved  fast  in  adduction.  All  the  extrinsic 
muscles  were  treated  and  responded  quickly.  So  much  improved 
that  she  ventured  to  take  in  the  St.  Louis  fair  and  did  it  without 
detriment.  This  case  increased  in  esophoria  to  14°  but  the  abduc- 
tion was  9°  notwithstanding,  and,  in  two  months,  she  showed 
esophoria  8°.  She  took  off  her  glasses;  has  painted;  kept  books, 
and   remains   well  and,   to  this  time,  does  not  wear  glasses. 

Case  14.     July  24th.,  1905.      Miss  C,  age  27.     Teacher  of  draw- 
ing.     Broke    down    during    study,    five    years    before.      Spent    I 
years  in  Colorado  for  health  and  gained  25  pounds.     On  returning 
to   work   lost  20   pounds.     A   neighboring  oculist,   on   examination 
under  "drops"  pronounced,  "no  glasses  needed."     She  was  a  slim 


196  HAZEN'S  NEW   FINDINGS 

nervous  organization  full  of  ambition.  No  car  sickness  but  going 
to  church  always  gave  headache.  Pain  back,  of  head,  running 
down  into  spine.  Relief  very  quick.  No  more  headache  after 
five  treatments.  Although  attaining  to  50°  of  adduction  soon, 
exercise  continued  because  slow  and  want  of  facility  of  adjstment. 
Finished  in  27  treatments.  She  gained  in  weight  before  end  of 
treatment,  and  afterwards  engaged  in  active  pursuits  without 
relapse. 

Case  lo.  February  6th.,  1906.  Mr.  B.  A.  C,  neighboring  city. 
Age  29.  Pharmacist.  Has  been  fitted  with  glasses  by  five  oculists, 
one  in  Chicago,  the  others  in  other  cities.  Tenotomy,  three  times. 
Eyes  red  and  angry.  Riding  or  attending  theater  used  him  up. 
Pain,  smarting,  sticking  of  eyelids;  back  of  head,  temples  and 
shoulders,  on  pressure  of  hand  ,  would  get  temporary  relief.  Had 
taken  strychnia,  and  had  some  prism  exercise.  Esophoria  and  some 
hyperphoria.  Adduction  32°,  abduction  3  1-2°.  The  adjustments 
were  very  slow. 

Gave  general  discipline  of  all  the  muscles.  With  28  treatments 
was  entirely  relieved.  Have  no  report  after  two  months,  but  up 
to  that  time  was  all  that  could  be  desired. 

Case  16.  March  29th.,  1905.  Miss  B.  H.,  miniature  painter. 
Had  spent  several  years  in  France  and  Holland  under  the  best 
teachers  for  her  art,  and  opened  a  studio  in  New  York  City.  Be- 
came nervous  and  unable  to  work — had  not  thought  of  the  cause 
being  in  the  eyes  at  first.  But  eyeballs  became  swollen;  blurring; 
pain  in  the  eyeballs,  head,  temples,  extending  down  spine.  Con- 
sulted three  oculists  i  n  New  York  City.  The  duction  in  all  pairs 
of  muscles  was  unusually  good.  Adduction  40°  abduction  5°. 
Infra-  and  sursumduction,  2  1-2°.  In  two  weeks,  duction  of  all 
muscles  was  up  to  standard.  Able  to  read  without  headache. 
In  one  month  discharged.  Returned  to  her  profession,  opened  a 
studio  in  Chicago,  and  took  the  prize  for  miniature  painting  at  an 
exhibition  in  Philadelphia. 

Case  17.  March  11th.,  1906.  Canadian.  Age  about  40  years, 
Exophoria,  18°.  Hyperphoria  18°,  L.  E.  Emmetropia.  This 
case  was  remarkable  for  lack  of  pain.  She  was  wearing  4  ,  base  in 
over  one  eye  and  4°,  base  up  over  the  other  eye.  She  could  not 
get  along  without  these  on  the  street,  and  required  +1..25  D.  for 
near  work  in  addition. 

With  these  prisms,  she  could  adduct   13     and  infraduct,  2  1-4° • 

In  two  weeks  the  lateral  prism  was  taken  off  and  the  vertical 
changed   to  2°.      In   less   than   two  weeks    more  she  became  ortho- 


CASES  19? 

phoric  in  the  lateral  and  adducted  50°  and  the  verticals  1  1-2° 
with  a  2°  prism.  In  one  month  was  enabled  to  go  without  prisms 
indoors.  At  the  end  of  six  weeks,  she  wore  a  prism  of  2°  for  hyper- 
phoria and  a  blank  for  the  laterals. 

She  was  unable  to  continue  the  office  treatment  longer.  This 
case  was  treated  by  gymnastic  exercise  alone,  no  medicine  or  oper- 
ation. During  the  whole  treatment,  she  read  and  wrote  many 
hours  a  day.  I  have  not  the  least  doubt  but  the  vertical  muscles 
could  have  been  brought  to  Orthophoria  in  another  two  weeks' 
treatment  and  then  an  occasional  attention  over  a  period  of  three 
months  to  keep  them  balanced,  but  she  came  from  a  distance  and 
was  unable  to  remain  longer. 

Case  18.  May  31st.,  1907.  Miss  J.  D.,  age  28.  Had  trouble 
since  10  years  of  age.  Confined  to  housework,  because  she  could 
not  keep  books  for  her  father,  who  was  a  grocer.  Was  treated  for 
two  years,  and  refracted  several  times  by  one  of  the  best  oculists 
in  the  west.  Wearing  R.  E.  +1-50  +.25  at  180°,  L.  E  .  +  1.25 
+  25,  170°  V.  20/ xx  20+ xxx.  Carried  head  to  left  to  avoid 
diplopia;  intense  pain  if  turned  to  right.  Pain  in  temples,  forehead 
and  back  of  balls  and  occipit. 

Exophoria  10°;  adduction  9°;  verticals  normal.  Did  not  change 
glasses.  In  ten  days,  she  adducted  50°  Headache  gone.  In  one 
month  became  orthophoric,  and  remained  so  while  under  observation 
two   months   subsequently. 

She  at  once  commenced  studying,  and  has  been  able  to  fulfil  her 
duties   since. 

Case  19.  June,  1908.  J.  M.  M..  age  25.  R.  R.  Mail  agente 
Suddenly  broke  down  on  duty  and  was  about  to  resign.  Unable 
to  read  on  train. 

Esophoria,  1°.  Verticals  normal.  Adduction,  15°.  For  tem- 
porary use,  gave  R.  and  L.  +1.25  D.  and  treated  him  when  at 
home.  In  24  treatments  adducted  50°.  He  has  kept  at  his  duty 
since  that  time,  and  does  not  use  glasses,  and  is  entirely  free  from 
apprehension  about  the  eyes. 

Case  20.  June  16th.,  1908.  E.  M.  S.,  age  37.  From  a  neigh- 
boring city.  Editor  and  Postmaster.  Troubled  with  eyes  for 
15  years.  Fitted  by  occulists  with  R.  and  L. — 50  at  180°  and  changed 
frequently  on  both  sides  of  the  emmetropic  line.  Exophoria  of 
laterals,  verticals  normal.  He  showed  no  insufficiency  at  readine 
point  but  could  not  jump  5°  adduction  for  distance,  but  by  pre- 
senting 1°  increase  at  a  time  could  go  to  17°,    slow    fusing.      Was 


l'.is  HAZEN'S  NEW   FINDINGS 

told  by  former  oculist  that  he  must  give  up  his  work  for  six  months 
and    take   a    rest. 

This  man  is  of  good  physique,  but  very  nervous  and  full  of  fore- 
bodings. Whenever  he  went  home,  he  would  tax  his  eyes  severely 
in  an  effort  to  catch  up  with  his  work,  which  had  necessarily  been 
neglected.  Notwithstanding,  he  progressed  and  attained  60° 
adduction  in  26  treatments,  and  has  not  only  returned  to  regular 
duty,  but  preformed  extra  duty  to  catch  up  back  work,  and  for  a 
short  time  did  not  only  his  own  work,  but  that  of  his  stenographer 
who  went  on  a  vacation.  The  nervousness  has  not  wholly  subsided. 
unless  his  inordinate  ambition  for  work  is  checked,  it  is  to  be  feared 
he  will  break  down,  but  he  is  going  it  at  full  pace  at  the  present 
time. 

Case  21.  August  7th.,  1908.  Wm.  McE.  Age  44.  Traveling 
salesman.  Been  troublrd  25  years.  Broke  down  suddenly  at 
school.  Has  been  fitted  fifteen  times  by  eminent  oculists  all  over 
the  country,  east  and  west.  The  variation  in  formula  is  remark- 
ably slight.  Some  added  prisms.  Has  worn  glasses  for  twenty 
years.  Wearing  R.  and  L.  +.75  at  180°.  Lids  droop  a  little 
blush  of  conjunctiva.  Had  twitching  of  lids;  learned  to  keep  out 
of  crowds;  pain  at  occipit  extending  down  spine.  Has  had  three 
attacks  of  sudden  blindness. 

Exophoria  2°  R,  hyperphoria,  1-2°.  Adduction,  25°.  Infra- 
duction  1  1-2°.  In  twenty  treatments  became  orthophoric  and 
duction  standard,  both  lateral  and  vertical.  Reads  as  much  as 
he  wants  to — even  on  cars — no  pain  and  sometimes  does  away 
with   glasses. 

Case  22.  September  8th.,  1910.  Mrs.  S.,  physician's  wife, 
and  a  musician.  Age  32.  Been  troubled  since  a  girl  going  'o 
school;  s  ck  headache  once  or  twice  a  week;  never  went  to  eh  b, 
amusements  or  rode  on  cars,  or  went  into  a  crowd,  without  ving 
to  pay  the  penalty  of  hours  in  bed  with  hot  cloths  on  hea  Pain 

in   top  and  forehead;   tender  spot  occipit  and   a   little  to  one  side. 

Fitted  12  years  ago  in  office  of  one  of  the  best  known  oculists  in 
the  U.  S.,  after  going  to  his  office  twenty  times.  Glasses  were 
fitted  and  changed  about  a  dozen  times.  She  had  worn  these  for 
12  years. 

There  was  no  particular  change  in  her  condition  before  or  since 
the  fitting.  Could  use  her  eye  for  15  to  20  minutes,  but  soon  ha 
symptoms  of  headache  and  sickness.  Glasses  R.  E.,  — |— 1.25  +  25. 
30°.  L.  E.  +1.25  V  +20/xxx.  Es  3°  Verticals  orthophoria. 
Adduction,  7°;  abduction  5°;  Infraduction,  2°;  sursumduction, 
1   1-4  . 


CASES  199 

For  a  month,  the  duction  stood  almost  without  improvement. 
Either  there  was  no  fusion  faculty,  or  the  patient  did  not,  from 
habit,  make  any  effort  to  use  the  muscles.  1  think  it  was  the  latter, 
for,  in  less  than  a  week  she  adducted  40°,  improving  steadily  and 
in  two  weeks  attained  50°  and  was  discharged  with  5°  of  esophoria. 
Having  broken  her  glasses  about  this  time,  she  was  compelled  to 
go  without  them,  and  finding  that  she  got  along  as  well  without 
them  as  with  them,  she  has  not  worn  them  for  two  months  and 
thinks  she  does  not  need  them.  Is  able  to  do  anything  she  chooses 
and  no  return  of  pain  or  discomfort. 

I  have  had  three  cases  of  pronounced  chorea,  two  of  them  resulting 
satisfactorily,  but  the  third  relapsed  after  two  years.  One,  a  boy 
of  12  years  was  perfectly  cured  and  has  used  his  eyes  uncommonly 
for  one  so  young.  Another,  a  musician  has  been  free  from  trouble 
for  four  years,  although  he  uses  his  eyes  as  a  musician,  playing 
in    an    orchestra    in    a    theater.     Xo    medicine    used. 


200  HAZEN'S  NEW  FINDINGS 

OCULAR  TRAPEZE. 

And  Modification  of  Landolt's  Ophthalmo-dyanomometer. 

To  further  facilitate  the  management  of  these  cases, 
in  diagnoses  and  treatment,  I  have  devised  the  "Ocular 
Trapeze,"  and  a  Modification  of  Landolt's  Ophthalmo- 
dyanomometer. 

In  the  former  edition  of  "New  Findings,"  it  was  recom- 
mended that  the  light  (the  best  is  a  small  frosted  electric 
bulb)  be  placed  on  the  left  side  and  a  little  behind  the 
patient,  with  the  patient  behind  the  Kratometer,  at  a 
distance  of  ten  or  twelve  feet  from  a  looking  glass,  at 
least  the  size  of  21  by  27  inches,  placed  on  the  wall  in 
front.  This  method  of  using  the  light  has  proved  satis- 
factory. The  light  is  at  hand  to  turn  on  and  off,  and 
saves  considerable  expense  in  appliances,  for  20  feet 
distance,  and  makes  it  possible  to  use  a  short  room  and 
get  the  proper  length. 

Then,  for  examining  convergence,  the  light  is  in  right 
position,  as  well  as  being  convenient  for  making  notes  in 
the  somewhat  darkened  room  which  is  the  best  for  this 
kind   of  work. 

It  is  necessary  to  have  a  black  background,  and  the 
patient  should  be  free  from  such  surroundings  as  glass, 
pictures,  or  anything  that  will  reflect  light  and  cause 
confusion  with  the  object  light  in  the  looking  glass,  on 
which  he  is  to  concentrate  his  gaze. 

In  order  to  make  the  method  a  still  more  serviceable 
one,  I  have  devised  this  Trapeze,  made  of  3-8  iron  rod 
in  the  form  of  the  staple  21  inches  inside  measurement 
and  long  enough  to  reach  from  the  ceiling  to  within 
5  feet,  7  inches  of  the  floor,  and  hung  by  hooks  in  the 
end  of  the  rod,  into  eye  hooks,  screwed  into  the  ceiling. 
The  rod  between  the  legs  of  this  staple  is  horizontal  and 
at  right  angles  to  the  vertical  rod. 


OCULAR  TRAPEZE 


201 


— 

o 

— 


- 


302  HAZEN'S  NEW  FINDINGS 

Fifteen  inches  above  this  horizontal  bar  is  another 
bar  running  across  from  leg  to  leg  and  parallel  to  the 
lower  one.  Into  this  space  between  the  bars,  a  piece  of 
tin.  painted  black,  is  hung,  so  as  to  easily  swing  in  the 
space  described.  Two  loops  of  tin  are  riveted  to  the 
sheet,  and  form  hinges  around  the  lower  bar  and  serve 
to  hold  in  position,  when  thrown  up  between  the  bars, 
or  let  down  below  the  lower  one.  On  this  trapeze  are 
rings,  one  at  each  of  the  four  corners,  and  one  between 
the  two  hinges  of  the  lower  bar.  The  two  upper  rings 
enable  one  to  thread  a  string  through  to  give  the  vertical 
movement  to  the  light,  for  testing  the  vertical  muscles; 
the  ring  between  the  hinges  on  the  lower  bar  to  give  the 
horizontal  movement  for  testing  the  lateral  muscles  in 
cases  of  paralysis  of  these  muscles. 

The  patient  is  seated  just  in  front  of  the  trapeze,  before 
a  stand,  onto  which  the  Kratometer  is  fastened.  The 
electric  light  is  hung  upon  the  Trapeze,  at  the  left  side, 
behind  the  patient,  and  the  operator  is  at  his  right  hand. 

In  this  simple  and  inexpensive  apparatus,  the  operator 
has,  together  with  the  Kratometer,  a  complete  contri- 
vance by  which  he  can  go  through  all  the  tests  and  exer- 
cises of  the  muscles,  as  well  as  test  vision  and  detect 
presence  of  astigmatism  of  the  muscles,  without  getting 
off  his  stool  at  the  patient's  side. 

The  tests  by  movement  of  the  light  horizontally  or 
vertically  placed,  which  the  books  describe,  to  ascertain 
the  muscle  paralyzed,  are  very  conveniently  performed 
with  this  device.  The  operator  has  at  hand,  the  other 
and  more  modern  tests  with  the  Maddox  rod,  double 
prism  and  red  glass;  he  has  the  light  in  position  for  testing 
convergence  and  accommodation,  and  the  Von  Graefe 
test  for  insufficiency;  he  can  hang  on  this  trapeze,  the 
looking  glass  test  type,  the  lines  of  astigmatism  or  the 
single  line  to  use  with  the  double  Maddox  prism  for  test 


<HTI,\i;  TKAriCXE 


203 


of  Cyclophoria  at  a  distance,  or  these  may  be  pasted  on 
one  side  of  the  tin — better  on  the  side  that  faces  the  glass, 
when  it  is  put  up  between  the  two  horizontal  bars.  He 
also  has  the  test  for  cyclophoria  at  the  reading  distance. 

To  obtain  a  small  aperture  for  testing  the  muscles, 
particularly  the  verticals —  a  half  inch  hole  may  be  made 
in  the  tin  pkte,  in  the  left  lower  corner  when  let  down. 
A  smaller  one  can  also  be  made  in  this  region  if  thought 
best.     The  electric  bulb  is  hung  behind  this  hole. 

The  electric  light  may  be  held  in  one  hand  of  the  oper- 
ator to  illuminate  the  letters,  and  the  right  hand  index 
finger  can  point  out  the  letter  he  wishes  named,  or  by 
reflectors  fastened  to  the  trapeze,  the  whole  surface  can 
be  properly  illuminated. 

Glasses  may  be  fitted  with  this  device,  and  nearly  all 
the  tests,  regarding  the  function  of  vision,  may  be  per- 
formed. 


Fig.  4. 

Convergence  Rod— with  Modification  of  Landolt's  Ophthalmo-dyan)mometer. 


OTOLOGY 


NEW  FINDINGS  IN  OTOLOGY. 

OTITIS  MEDIA. 
A  Plea  for  the  More  Frequent  Use  of  the   Eustachian  Catheter. 

It  is  gratifying  to  one  who  spans  a  generation  in  his 
profession  to  see  the  advances  that  have  been  made  in 
the  art  of  surgery,  in  solving  the  difficulties  that  used  to 
be  impenetrable  to  the  skill  of  the  surgeons  of  earlier 
times.  At  the  time  of  the  Civil  War  ,a  person  shot  in 
the  abdomen  was  portentious  of  an  early  demise,  and 
the  surgeon  but  shook  his  head  when  appealed  to.  In- 
flammations that  started  in  the  right  illiac  fossa  spread 
to  the  perotinitis,  in  which  fatality  was  great.  In  these 
days  the  calvarium  is  opened  with  impunity,  and  the 
surgeon  seeks  abscesses  in  this  cavity,  as  former  men 
sought  them  in  hand  or  foot.  The  surgery  of  Otology 
is  especially  brilliant  now,  and  exemplifies  the  boldness 
and  consummate  skill  of  the  surgeon  of  the  day.  Lives 
are  today  saved  by  the  knowledge  of  the  aurist  that 
would,  if  the  case  had  occurred  in  former  days,  perhaps 
have  been  regarded  as  a  mystery,  or  knowing  its  patho- 
logical condition,  the  surgeon  might  yet  have  been  un- 
able to  cope  with  its  presentation. 

There  are  yet  many  who  die  with  purulent  inflam- 
mations of  the  ear  that  produce  abscesses  of  the  brain,  the 
sequel  of  scarlet  fever,  measles,  diphtheria,  variola,  eri- 
sypelas,  typhoid  fever,  pneumonia,  diabetes,  Bright's 
disease,  bronchial  catarrh,  tuberculosis,  puerperal  fever, 
influenza  and  lagrippe,  unrecognized,  or  they  are  al- 
lowed to  succumb  to  the  secondary  condition,  without 
proper  attempts  to  relieve,  and  this  sequel,  which  we 
call  the  real  cause  of  death,  is  covered  up  in  the  diagnosis 
of  the  original  affection. 

The  cavity  of  the  tympanum,  situated  so  near  to 
the  brain,  has  its  mucous  lining  extending  to  the  throat 
through    the   Eustachian    tube,    through   which   so   many 


208  HAZ E N 'S  NEW  FIND1 NGS 

diseases  incite  to  its  inflammation.  This  complication 
becomes  the  most  serious  part  of  the  sickness  which 
brought  it  on.  It  is  said  that  99  per  cent  of  cases  of  in- 
fection of  the  middle  ear,  are  through  the  /Eustachian 
tube.  (Andrews.)  These  are  too  often  considered 
lightly  by  the  attending  physician,  and  if  the  case  re- 
covers from  the  fever,  a  running  ear  is  thought  too  slight 
to  be  considered,  and  it  is  left  to  be  "outgrown." 

But  while  fault  may  justly  be  found  with  general 
practitioners  for  regarding  too  lightly  the  complications 
that  arise  and  involve  the  ear,  we  think  we  see  the  oppo- 
site extreme  in  the  hands  of  the  specialist.  It  is  not  the 
desire  of  the  writer  to  inveigh  against  the  judgment  of 
the  specialists  who  have  so  cautiously  proceeded  to  so 
important  an  operation,  and  who  have  saved  a  few  on 
the  extreme  limits  of  dissolution,  but  rather  he  would 
commend  the  skill  and  daring  that  probes  the  cavities  so 
near  to  vital  parts.  The  more  simple  operation  of  open- 
ing the  mastoid  antrum  has  become  familiar,  but  he 
now  seeks  the  accumulated  pus  that  has  burrowed  to  the 
meninges  through  the  tegmen  tympanum  and  around 
into  the  sinuses  and  sometimes  buried  beneath  the  Gas- 
serion  gangleon  and  in  the  region  of  the  torcular  Hero- 
phili,  or  in  the  jugular  veins.  Nothing  daunted,  the 
hand  of  the  surgeon  follows  it  and  snatches  from  Death 
the  victim  that  has  been  dragged  to  the  door.  The 
study  of  brain  abscesses  caused  by  middle  ear  diseases 
took  fresh  impetus  after  the  work  of  Macewen  of  1893, 
and  has  progressed  steadily  since.  Nevertheless  it  seems 
to  the  writer  that  there  is  no  necessity  for  the  frequency 
of  these  operations  at  the  present  day. 

Surgical  sanction  is  being  asked  by  some  of  them  to 
open  the  antrum  mastoides  in  cases  of  chronic  otitis 
media,  where  there  is  no  indication  of  acute  inflamma- 
tory exacerbations,  and  also  its  performance  more  fre- 
quently in  the  acute  forms. 

Twenty  years  ago  there  were  but  few  operations  on 
the  Mastoid  Cells.  There  are  now  as  many  Antrectomy 
performed  in  one  hospital  in  New  York  City  in  one 
year,  as  were  performed  in  all  of  them  in  ten  years  be- 
fore. A  surgeon  at  a  meeting  of  the  Otological  Section 
of  the  Academy  of  Medicine,   in  New  York  City,   Feb- 


OTITIS  MEDIA  209 

ruary  13,  1903,  asserted  that  he  had  examined  the  reports 
of  three  institutions  of  New  York,  for  ten  years,  and 
there  were  as  many  operations  performed  in  three  weeks, 
in  one  of  these  institutions,  as  during  the  ten  years  men- 
tioned, in  the  three. 

The  following  tables  will  give  some  idea  of  the  in- 
creased percentage  of  operations  on  the  same  class  of 
diseases.  The  operations  on  the  mastoid  in  the  first 
table,  include  the  mere  incisions  of  abcesses  behind  the 
ear  (Wilde's),  which  was  a  very  common  operation, 
whereas  the  opening  of  the  cells  was  a  very  uncommon 
one. 

The  first  table  is  taken  from  Dr.  Roosa's  book  on 
"The  Diseases  of  the  Ear,"  fourth  edition  (1891). 

The  following  table  is  compiled  from  late  reports: 

Mat'd 

CASES    YRS.    AFF.    WILDS  INCISIOK 

Manhattan  Eye  and  Ear  Hospital  14,720  17  110  105  and  Mastoid 

Brooklyn  Eye  and  Ear  Hospital  18,366  18  91  126 

N.  Y.  Opth.  and  Aural  Institute  14,634  17  112  108 

Mass.  Charitable  Eye  and  Ear  9,533  3  62     30  (estimated) 

Newark  Chart'Eye    and  Ear  Inf.  3,021  3  22     15 

Illinois  Eye  and  Ear  Inf.  2,464  4  8     16 

N.  Y.  Charity  Hospital  20  1  1        11 

Dr.  Roosa's  practice  5,797  22  59     42 

Total  68,555  443 

The  following  is  compiled  from  late  reports: 

HOSP  TAL  CASES    VR    MASd'    AFF.    MAs'd    OP'n 

Royal  Ear  Clinic,  Halle  2,425       1 

Royal  Polv  Clinic,  Munich  2,831 

N.  Y.  Eye  and  Ear  Inf.  10,235  1902 

Manhattan  Eye  and  Ear  Hospital  4,526  1901 
Ditto  5,314  1902 

Total  25,331  746 

The  greater  frequency  of  these  operations,  it  cannot 
be  doubted,  is  to  a  great  extent,  on  account  of  the  skill 
attained  and  the  confidence  acquired  in  their  perform- 
ance. But  to  the  author  it  seems  there  is  another  reason, 
which  will  be  made  maifest  in  due  time. 

The  minds  of  men  run  in  grooves,  ruts  and  surveyed 
channels.     Fashion   guides,    customs   prevail,    and   creeds 


129 

44 

410 

334 

143 

128 

136 

111 

•210  HAZEN'S  NEW  FINDINGS 

bind  the  thoughts  of  each  time  and  period.  The  bell- 
wether leaps  over  an  imaginary  or  real  obstruction  and 
the  flock  goes  with  him  into  green  pastures  or  into  the 
turbulent  sea.  Now  and  then  the  non-conformist  stands 
beside  the  road  and  dares  to  question  and  cry  Halt! 
but  the  world  goes  on,  and  often  the  objector  dissenter 
or  the  doubter  is  trampled  out  of  sight,  his  warning  un- 
heeded until  a  second  or  third  may  dare  to  demur,  and  if 
he  have  influence  becomes  a  bell-wether  on  his  own  tan- 
gent. It  is  as  true  in  medicine  as  in  other  walks  of  life, 
and  its  history  is  full  of  blind,  headlong  precipitation  as 
any  other  field  that  is  not  built  on  fact  and  reason. 

The  profession  in  Otology  seems  now  to  be  faced  all 
one  way,  and  that  toward  the  development  of  the  path 
of  curing  Otitis  Media  Purulenta  by  the  mastoid  route, 
while  the  labors  of  the  former  generation  on  the  treat- 
ment of  the  Eustachian  tube,  is  ignored.  The  author 
believes  that  this  is  one  of  the  reasons  for  the  readi- 
ness with  which  the  "radical  operation"  is  so  often  per- 
formed. 

The  writer  hopes  to  make  good  his  remarks,  that  may 
seem  to  the  reader  pretentious,  in  showing  his  methods, 
followed   in  treatment  of  middle  ear  inflammations. 

The  operation  of  treflning  the  mastoid  process  itself 
fell  into  disrepute  because  a  Danish  surgeon  by  the  name 
of  Berger  in  1792  caused  it  to  be  performed  upon  himself 
for  "deafness  wrhich  was  accompanied  by  vertigo,  head- 
ache and  noise  in  both  ears."  Meningitis  resulted  and 
the  patient  died  in  a  few  days. 

The  diseases  of  the  ear  and  their  treatment  were  a 
jumble  of  contradictions  and  inconsistances  down  to  the 
generation  which  has  just  about  passed  off  the  stage. 

Dr.  D.  B.  St.  .John  Roosa,  in  his  work  on  "Diseases 
of  the  Ear,"  gives  due  credit  to  foreign  authors  and  espec- 
ially to  Wilde  (1843)  of  St.  Mark's  Hospital,  whom  he  says 
"probably  did  more  to  place  our  science  upon  a  sound 
basis,  than  anything  that  has  been  done  in  Otology 
since  the  days  of  Valsalvia."  He  recognizes  the  works 
of  Toynbee,  Von  Troltsch,  Politzer,  Gruber,  Weber, 
Rudinger  ,Hinton  and  others  and  many  in  this  country — 
Knapp,  Turnbull,  Blake,  Burnett  and  Pomoroy,  but 
there   are   none   to  whom  America   is   so   indebted   as   to 


OTITIS  MEDIA  211 

Dr.  Roosa  himself.  For  clearness  of  classification  and 
common  sense,  he  is  excelled  by  none  other  in  his  writings. 
On  treatment  he  is  most  satistactoiy. 

The  drift  of  all  the  discussions  on  the  middle  ear  dis- 
eases and  in  their  more  severe  forms  involving  the  mas- 
toid cells  particularly  is  toward  giving  vent  to  the  pus 
collection,  in  the  first  case,  by  paracentesis  of  the  mem- 
brane, and  in  the  second,  by  Antrectomy. 

This  latter  operation  is  now  performed  in  acute  sup- 
purations, and  also  in  the  chronic  form,  for  purposes 
of  thorough  cleaning,  where  in  neither  case,  there  is 
immediate  fear  of  involvement  of  the  brain.  In  ihe 
many  discussions  for  several  years,  and  the  giving  of  the 
history  of  many  cases,  there  is  no  mention  of  getting 
vent  or  drainage  through  the  Eustachian  tube  by  use  of 
the  Catheter.  The  manipulation  of  the  Catheter  seems 
to  be  one  of  the  lost  arts. 

Some  mention  occasionally  is  made  of  the  cautious  use 
of  the  Politzer  bag  and  some  authors  advocate  use  of 
the  Eustachian  bogie,  while  others  mention  repeated 
incisions  of  the  drum  membrane  and  cleaning  the  tym- 
panum by  a  thorough  wet  or  dry  method. 

The  experience  of  one  who  has  labored  in  a  different 
direction  to  relieve  these  most  difficult  and  trying  group 
of  diseases,  may  be  of  interest  to  those  who  come  in  con- 
tact with  them. 

When  the  method  hereinafter  described,  was  insti- 
tuted, the  operation  on  the  mastoid  was  considered  a 
capital  operation,  and  the  wish  was  to  avoid  it  if  possible. 
This  may  be  the  reason  of  its  inception,  and  promotion 
and  the  writer  finds  it  sufficient  in  a  very  large  percent- 
age of  cases.  This  is  the  use  of  the  Eustachian  catheter 
and  injections  of  a  bactericide  through  it  to  the  seat  of 
the  disease. 

The  Eustachian  tube  is  the  natural  drainage  tube 
for  the  cavity  of  the  Tympanum,  and  when  this  tube 
becomes  clogged,  the  writer  deems  it  the  first,  and  al- 
ways, the  duty  of  the  surgeon  to  restore  it  to  its  function, 
by  the  best  possible  method.  Until  the  natural  drainage 
is  established,  by  some  means,  the  case  cannot  get  well. 

The  writer,  when  a  boy,  moved  to  Ohio,  and  was  sent 
with  a  laborer,  to  drain  a  piece  of  wet  land.     When  his 


2 12  1 1 A  Z  E  N  s  X  B  W  FINDINGS 

uncle  came  out  to  see  the  progress  of  the  work,  he  found 
us  commencing  our  ditch  on  the  highland  end.  He  has 
never  quite  gotten  over  the  chagrin  caused  by  this  proof 
of  his  lack  of  common  sense  thus  exhibited. 

This  tube  is  a  little  over  an  inch  in  length,  divided 
into  two  portions,  the  osseous  upper  portion,  called  the 
isthmus,  1^2  to  2mm.  in  height  and  l/2  to  ^4  mm.  in  width, 
widening  out  rapidly  as  it  proceeds  to  the  throat  in  the 
cartilagenous  portion,  at  an  angle,  in  the  adult,  of  about 
40  degrees  in  direction,  measuring  at  its  orifice  9mm. 
high,  and  5mm.  broad.  (Roosa.)  The  length,  direction 
and  size,  varying  in  age  and  in  individuals  of  adult  age. 
It  is  as  large  in  the  tympanic  orifice,  in  the  child,  as  in 
the  adult.  Besides  being  more  horizontal  in  the  child, 
it  is  shorter  and  wider  and  consequently  fluid  passes 
more  readily  from  the  tympanic  cavity,  through  it  into 
the  throat.  (Macewen.)  The  ciliated  epithelium  which 
lines  the  Eustachian  tube,  and  partly  the  tympanic 
cavity,  has  the  movement  of  the  cilia  toward  the  pharynx. 
(Macewen.) 

The  tegmen  tympani  is  a  wide  plate  of  thin  bone,  lying 
between  the  conuous  ear  cavity  and  the  dura  mater 
under  the  brain.  It  is  continuous  from  the  escaping 
Eustachian  tube,  anteriorly,  over  the  tympanum  (the 
attic)  and  continued  over  the  Antrum  in  the  mastoid 
cells  (the  latter  portion  sometimes  called  the  tegmen 
antre.)  In  adults  the  antrum  is  somewhat  dropped 
down,  and  has  not  quite  the  straight  relation  as  in  child- 
hood, but  this  only  forms  a  more  secure  cup  for  the  pus 
that  may  be  received  from  the  tympanum.  The  bone  is 
very  thin  and  often  very  defective.  The  petro-squamous 
suture  is  sometimes  large  enough  to  constitute  a  perfect 
"dehiscence"  of  the  roof.  (Broca.)  A  straight  probe 
thrust  into  the  opened  antrum,  in  the  case  of  the  child, 
can  be  passed  through  the  tympanum,  over  the  audits 
(touching  the  ossicles)  when  it  will  engage  in  the  Eu- 
stachian tube  on  the  other  side  of  the  tympanum. 
(Broca.)  This  continuous  roof  is  covered  over  with 
periostium  and  lined  with  mucous  membrane,  forming 
a  direct  guide  for  a  column  of  air  projected  through  the 
Eustachian  tube,  through  the  tympanum  and  into  the 
antrum  of  the  mastoid  cells. 


OTITIS  MEDIA  213 

EUSTACHIAN  CATHETER. 

Why,  in  late  years,  the  disuse  of  the  Eustachian 
catheter,  with  injections  into  the  middle  ear,  has  come 
about,  is  difficult  to  explain.  But  that  attention  is  led 
off  to  the  more  brilliant  and  difficult  course  of  procedure, 
is  quite  evident. 

The  catheter  requires  skillful  manipulation,  with 
a  good  "muscular  sense,"  and  the  time  put  in  in  acquir- 
ing the  skill  is  well  repaid.  In  the  time  of  Wilde,  Toyn- 
bee,  Yon  Trolsch  and  Hinton,  the  catheter  was  used 
much  more  than  at  this  time.  More  was  done  to  get 
drainage  by  the  Eustachian  tube,  and  injections  of  the 
tube  were  frequently  advocated.  The  history  of  the  in- 
strument does  not  show  there  has  been  mischief  done 
with  it.  Xo  cases  of  death  have  been  reported  In  the 
hands  of  reputable  physicians. 

In  regard  to  the  manipulation  of  this  instrument, 
the  directions  given  by  the  books  are  almost  all  alike  in 
directing,  that  on  passing  the  catheter,  it  should  be  car- 
ried on  to  the  posterior  wall  of  the  pharynx,  and  then 
drawn  forward,  and  while  turning  the  beak  toward  the 
tube,  to  let  it  ride  over  the  posterior  lip  of  the  trumpet- 
shaped  orifice  of  the  tube,  which  is  generally  aided  by 
the  patient  lifting  the  palate.  The  carrying  of  the 
catheter  to  the  posterior  zvall  is  not  necessary,  and  when 
done,  the  patient  will  invariably  draw  up  the  palate  and 
catch  the  catheter,  and  this  incident  is  the  most  disagree- 
able part  of  the  procedure,  and  very  often  the  patient 
demands  that  it  be  taken  out.  The  second  hurt  comes 
on  in  riding  over  the  lip  of  the  tube.  The  catheter 
should  be  carried  in  only  so  far  as  the  posterior  nares 
and  turned  about  the  corner  and  into  the  tube  without 
passing  so  far  back  that  when  the  patient  swallows,  he 
can  joggle  the  catheter.  If  the  catheter  can  be  touched 
by  the  palate  on  swallowing,  it  is  too  far  in.  When  the 
entrance  of  the  Eustachian  catheter  is  thus  gained,  of 
course  the  fossa  of  Rosenmuller  is  not  reached.  Some- 
times this  posterior  lip  is  quite  prominent  and  there  is 
much  pain  in  riding  over  it. 


•Jit  HAZEN'S  NEW  FINDINGS 

DIAGNOSTIC  OR  AUSCULTATING  TUBE. 

The  diagonistic  or  auscultating  tube  should  always  be 
used.  I  would  as  soon  dispense  with  the  receiver  in  tele- 
phoning as  I  would  with  it,  in  examining  the  ear.  One 
who  uses  it  constantly  can  learn  much  of  the  condition 
of  the  tube,  and  I  am  in  accord  with  Kramer  in  his  dec- 
larations that  much  can  be  learned  thereby.  He  goes 
no  farther  in  this  than  the  declarations  made  in  regard 
to  the  auscultations  of  the  chest.  I  prefer  a  silver  cathe- 
ter, although  I  sometimes  use  a  vulcanized  one  but  am 
chary  with  these  in  refactory  patients,  for  fear  they 
will  be  broken.  Putting  one  end  of  the  diagnostic  tube 
in  the  hand  of  the  patient  and  directing  him  to  put  it 
in  the  ear  when  the  proper  time  comes,  holding  the  cathe- 
ter in  the  hand  best  suited  for  the  side  to  catheterize 
(left  hand  for  the  left  nostril  of  the  patient,  amd  right 
hand  for  the  right  nostril)  and  placing  the  other  arm 
across  the  shoulder,  with  the  fingers  on  the  occiput  of  the 
patient  I  seldom  have  difficulty,  when  the  nostril  has 
room  enough,  and  the  patient  is  over  ten  years  of  age. 
Children  in  this  country  are  not  sufficiently  disciplined 
by  parents,  to  be  handled  by  a  surgeon,  and  sometimes  it 
is  necessary  to  wrap  them  up  in  a  sheet  or  blanket  to 
accomplish  a  very  trivial  operation. 

It  is  often  advisable  to  use  a  swab  with  cocaine.  To 
cocanize  the  orifice  of  the  Eustachian  tube,  wTap  a 
"cable  temple"  of  a  spectacle  frame,  with  cotton  satu- 
rated with  a  solution  of  cocaine  and  carry  it  into  the 
nares  in  such  a  way  that  it  will  hug  the  floor  and  outer 
wall  of  the  nares,  and  when  arriving  at  the  posterior 
nares,  it  will  turn  toward  the  end  of  the  tube;  this  will 
not  only  anaesthetize  but  swab  this  locality. 

In  the  beginning  of  my  practice,  I  used  to  occasion- 
ally have  a  faint  with  some  susceptible  patients,  but  I 
learned  that  this  was  much  my  own  want  of  confidence 
or  assuring  manner.  If  I  see  any  tendency  this  way,  I 
wrap  them  on  the  knuckles  with  the  end  of  the  diagnos- 
tic tube:  with  some  have  dipped  my  finger  in  water, 
and  snapped  in  the  face  of  the  patient,  when  they  will 
generally  come  to  time.  Giving  them  something  to  do 
in   placing  the   diagnostic   tube  in   their  ear  is  generally 


CATHETER  VS.  POLITIZER   BAG  215 

sufficient  to  direct  their  attention  from  the  catheter.  Then 
again  much  explanation  of  the  process  to  the  patient 
previous  to  its  performance,  is  only  magnifying  the  act 
in  the  mind  of  the  patient. 

CATHETER  VS.  POLITIZER  BAG. 

The  superiority  of  the  catheter  over  Politzer's-bag 
method  of  inflating  the  Eustachian  tube  when  there  is 
fluid  or  pus  in  the  middle  ear,  is  very  great.  The  Eus- 
tachian catheter  occupies  only  a  portion  of  the  caliber 
of  the  tube,  and  the  propulsion  of  the  air  into  it,  allows 
a  return  current  past  the  beak  into  the  pharynx,  carry- 
ing the  accumulated  contents  with  it.  Whereas  in  the  case 
of  the  Politzer  the  pressure  of  the  body  of  air,  acting 
upon  the  contents  of  the  tube,  drives  it  forward,  and 
probably  over  the  audit  us  ad  antrum  into  the  mastoid 
antrum.  The  air  penetrates  the  middle  ear  and  breaks 
up  the  secretions,  but  inevitably,  the  contents  of  the 
tympanum  must  be  more  or  less  driven  directly  that 
way,  as  it  is  in  direct  line,  and  has  the  ossicles  only  as 
an  obstacle  to  its  course,  which  must  be  swept  by  the 
projected  fluid.  The  result  of  Politzeration,  is  that  a 
portion  of  the  secretion  is  gotten  rid  of  over  the  auditus, 
and  it  breaks  up  the  bulbous  mass,  and  the  good  effect 
arises  from  the  penetration  of  the  air  into  the  cavity  of  the 
tympanum  and  the  disturbance  of  the  contents  which 
afterwards  drains  more  or  less  down  the  tube.  I  am  as 
reluctant  in  using  the  Politzer,  in  elderly  people  with 
fluid  in  the  Eustachian  tube,  as  I  am  of  incising  the 
drum.  I  don't  know  of  a  better  method  of  infecting  the 
mastoid  cells  with  the  fluids  of  the  tympanum,  than  this 
very  process  that  so  many  surgeons  use,  and  which,  not 
knowing  or  suspecting  this  consequence,  is  considered  as 
a  brilliant  and  effective  performance.  The  catheter  has 
no  such  effect,  but  cleans  out  the  tube  by  the  counter- 
action of  the  stream  of  air  forced  in  by  the  bag  from 
without.  Another  point  in  the  use  of  the  bag  for  inflation 
through  the  catheter.  I  have  the  nib  which  fits  the  end 
of  the  catheter,  on  a  rubber  tubing  about  two  inches  in 
length,  and  then  joined  to  the  air  bag.  The  hand  that 
presses  the  bag  need  not  then  be  in  line  with  the  cath- 
eter, but  be  below  it.     The  nib  thus  placed  in  the  cath- 


216  HAZEN'S  NEW  FINDINGS 

eter  will  bounce  out  if  there  is  too  much  resistance  to 
the  passage  of  the  air  into  the  catheter,  which  is  an  indica- 
tion that  it  is  out  of  place  or  some  other  cause  that  needs 
correction.     It  acts  as  a  saftey  valve. 

INJECTION  OF  FLUIDS. 

In  the  time  of  Wilde,  Von  Troltsch  and  Hinton,  in- 
jections were  advocated,  especially  in  the  treatment 
of  the  chronic  non-supurative  inflammation  of  the  Eu- 
stachian tube  and  middle  ear;  with  some  in  large  quan- 
tities, and  others  by  drops,  but  the  latter  of  greater 
trength;  sometimes  carrying  these  drops  into  the  mid- 
dle ear  by  a  middle  ear  catheter,  which  was  a  flexible 
tube  of  small  caliber  pushed  in  through  the  ordinary 
catheter.  Hinton  advocated  the  injection  of  the  middle 
ear  through  the  open  drum  down  the  Eustachian  tube, 
the  fluid  being  caught  in  a  cup  under  the  nose.  These 
medications  have  not  been  more  successful  in  the  treat- 
ment of  these  nonsuppurative  cases,  than  other  methods, 
and  probably  brought  about  the  disuse  of  injections  al- 
together. 

CHRONIC  NON-SUPPURATIVE  CATARRH. 

The  more  common  diseases  of  the  ear,  and  those  in 
which  so  much  has  been  attempted,  are  those  of  the  non- 
suppurative form  which  comes  on  insidiously,  and 
causes  the  deafness  of  old  age.  They  are  the  bane  of 
the  aurist,  and  tend  more  to  the  disparagement  of  his 
reputation  than  any  class  of  diseases  of  the  ear.  They 
are  generally  the  result  of  a  neglected  catarrh  which 
fastened  on  the  patient  in  childhood,  and  which  caused 
deafness  at  the  time,  but  which  broke  away,  and  the 
hearing  restored  to  a  degree,  but  which  left  a  chronic 
condition  wrhich  gradually  produces  changes,  that  when 
fixed  are  very  difficult  to  remedy.  This  chronic  condi- 
tion can  be  carried  hidden  in  the  cavity  of  thejiead,  and 
will   not,   like   the  chronic   inflammations  of  the  eye,   be 


MODERN   BACTERICIDAL   METHOD  217 

attended  to  because  of  appearances.  When  the  hearing 
is  reduced  in  the  second  ear,  to  losing  common  conver- 
sation, then  they  are  driven  to  the  aurist  and  expect 
quick   relief. 

MODERN  BACTERICIDAL  METHOD. 

Since  the  bactericidal  method  of  treatment  of  the 
purulent  affections,  it  seems  that  the  revivement  of  Eu- 
stachian injections  should  be  made  in  the  treatment  of 
those  diseases  which  give  muco-purulent  secretions.  The 
writer  has  for  more  than  twenty  years  injected  the  Eu- 
stachian tube  through  the  catheter,  in  these  forms  of  in- 
flammation of  the  middle  ear.  He  regards  it  the  first 
and  most  rational  proceedure  to  get  drainage  into  the 
pharnyx  ,and  that,  too,  before  the  paracentesis  of  the 
drum,  and  this  is  most  effectually  done  by  inflating  with 
the  catheter,  and  the  injections  of  fluid.  The  operation 
is  not  nearly  so  severe  as  paracentesis,  and  goes  directly 
toward  relieving  the  cause  of  the  severe  symptoms,  which 
in  the  opening  of  the  drum  only  relieves  the  pressure  at 
one  end  of  the  tract,  and  does  nothing  for  the  other 
where  the  disease  is  most  active  and  from  which  the 
trouble  arose. 

Since  the  recommendation  of  Bezold,  of  the  use  of 
boracic  acid  in  the  treatment  of  purulent  diseases  of  the 
middle  ear,  we  have  a  safe  and  effectual  remedy.  He 
however  recommended  weak  solutions  of  1  per  cent  in 
sterilized  water,  whereas  I  have  used  it  in  saturated  so- 
lutions, and  indeed  am  not  particular  that  all  of  it  is 
dissolved  in  the  hot  water,  but  try  to  carry  it  in  by  sus- 
pension. In  chronic  suppuration  where  the  drum  is  per- 
forated, I  can  sometimes  inject  the  Eustachian  tube 
clear  into  the  tympanum,  and  the  patient  often  turns  a 
few  drops  out  of  the  meatus.  My  method  is  to  place  the 
catheter,  and  make  sure  it  is  so,  by  the  diagnostic  tube, 


218  HAZEN'S  HEW  FINDINGS 

then  ask  the  patient  to  swell  the  cheeks  and  incline  the 
head  back  slightly,  then  push  the  fluid  through  the  cath- 
eter (two  or  three  drams)  with  a  Arm  but  steady  push. 
The  most  of  the  fluid,  at  once  flows  back  into  the  phar- 
n\  x,  and  with  it  some  of  the  secretion.  It  does  not  go 
into  the  throat,  if  the  cheeks  are  kept,  inflated.  The  cath- 
eter is  then  removed  and  the  patient  turns  to  a  spittoon, 
or  empties  the  contents  of  the  nose  into  a  napkin  held 
under  the  nose.  The  inflation  of  the  cheeks  is  impor- 
tant, for  if  the  fluid  goes  into  the  lower  pharnyx  it  may 
strangle  and  cause  coughing,  or  it  will  go  into  the  stom- 
ach, which  it  is  better  to  avoid. 

BACTERIOLOGY. 

Parallel  with  the  investigations  for  the  kind  of  micro- 
organisms found  in  the  pus  taken  from  the  tympanum, 
should  be  discovered  the  germicide  that  would  be  most 
effectual  in  their  destructions.  Then  the  knowledge 
that  is  said  to  be  already  ours,  the  micro-coccus  lance- 
alatus  the  pneumo-bacillus  of  Friedlander,  the  strep- 
tococcus pyogenes,  the  staphylo-coccus  pyogenes  aureus, 
albus  and  citreus;  the  klebs  Loeffler  bacillus,  the  bacillus 
of  influenza,  and  the  Diplococcus  introcellulares  min- 
ingitude,  will  be  of  some  utility  in  this  connection. 

The  new  chemical  substance  to  which  the  profes- 
sion is  directed  by  Professors  Frier  and  Novy  of  Michi- 
gan University  called  Acetozone,  might  be  of  great  serv- 
ice here.  I  have  not  tried  it,  but  here  make  the  sugges- 
tion. 

This  douching  through  the  catheter,  both  in  acute 
and  chronic  otitis  media  purulenta,  has  been  very  satis- 
factory, in  cases  before  and  after  the  drum  has  been  per- 
forated. The  medication  has  been  salutary  on  the  in- 
flamed mucous  membrane  at  the  entrance  of  the  tube, 
and  the  second  injection  is  better  endured  than  the  first, 


CLEANING  THE  TYMPANUM  219 

Indeed  the  patient  is  so  much  relieved,  that  in  the  ma- 
jority of  cases,  he  is  anxious  to  have  it  repeated.  I  con- 
tinue the  injections  of  the  Eustachian  tube,  so  long  as  1 
get  the  sound  of  fluid  on  its  inflation  through  the  cath- 
eter. There  can  be  no  more  satisfactory  result  in  re- 
lieving the  head  symptoms  and  restoring  the  function 
of  the  Eustachian  tube.  1  have  relieved  many  who  had 
the  more  severe  symptoms:  swelling  behind  the  ear, 
debilitated,  high  temperature,  and  severe  pain,  with 
symptoms  of  mastoid  complication,  with  these  injections. 

CLEANING  THE  TYMPANUM. 

To  facilitate  the  cleaning  of  the  cavity  of  the  tym 
panum  when  there  is  perforation  of  the  membrane,  I 
direct  that  the  patient  take  a  dropper  instead  of  a  syr- 
inge (which  latter  is  well  said  by  the  books,  cannot  be 
used  by  the  patient,  and  very  few  learn  to  use  it  on  an- 
other). The  patient,  himself,  can  use  the  dropper  and 
make  it  more  effectual  in  removing  the  secretions,  be 
they  cholesteatomatous  in  character  or  less  hardened 
secretion.  The  dropper  should  be  a  double  shoulder 
(French)  air  tight  and  smooth  at  the  end.  They  are 
directed  to  three-fourths  fill  the  dropper  with  the  fluid 
used,  always  warm,  incline  the  head  to  bring  the  ear 
treated  upward,  pass  the  small  end  within  the  drum  per- 
foration, press  it  all  out  into  the  tympanum,  then  draw 
it  back  again  press,  so  back  and  forward  two  to  five 
times,  when  the  dropper  is  filled  with  the  saturated  so- 
lution of  pus,  and  emptied,  then  more  solution;  proceed 
in  this  way  until  the  fluid  returns  into  the  dropper 
clear,  when  the  cavity  is  dried  and  a  powder  of  boracic 
acid  is  blown  in  the  meatus.  It  is  often  that  strings  of 
muco-purulent  matter  are  engaged  in  the  tube  or  drop- 
per, and  by  atmospheric  pressure  are  held  there  until 
they    are    drawn    out.     To    facilitate    the    opening    and 


220  HAZEN'S  NEW  FINDINGS 

drainage  of  the  Eustachian  tube,  I  direct  that  after 
cleaning,  the  ear  be  filled  with  the  injection  and  then  the 
tragus  be  pushed  down  to  stop  the  ear  and  give  a  pres- 
sure while  the  patient  swallows,  when  the  fluid  is  often 
tasted  in  the  pharnvx.  This  indicates  patulency  of  the 
tube. 

It  is  not  my  intention  to  dissertate  on  the  compli- 
cations found  in  otitis  media  purulenta.  Polypi,  etc., 
must  be  attended  to  as  they  arise;  but  in  all  cases  first, 
last  and  always,  there  is  the  duty  of  maintaining  good 
drainage  through  the  Eustachian  tube. 

DOUCHING  THE  NOSE. 

There  is  a  second  requisite,  fully  as  necessary,  and 
which  promotes  the  accomplishment  of  the  first,  viz:  the 
treatment  of  the  pharnvx.  Since  the  report  of  Dr. 
Roosa  of  the  dangers  of  the  Thudicum  or  Webster  douche 
this  instrument  has  gradually  become  less  common  in 
the  hands  of  reputable  physicians.  There  is  no  doubt, 
that  in  the  hands  of  those  best  instructed  in  its  use,  the 
fluid  used,  will  be  flooded  into  the  Eustachian  tubes  and 
sometimes  into  the  tympanum.  In  consequence,  when 
used  at  all,  the  medication  must  be  so  weak  that  it  is 
inocuous  in  the  tympanum,  and  this  would  render  it 
ineffective  in  the  pharnvx.  The  spray-apparatuses  that 
are  so  common  to-day  are  difficult  to  use,  and  in  the 
hands  of  the  patient,  are  very  inefficient.  A  fluid 
sprayed  is  always  cold,  which  is  another  objection. 

DOUCHE  AND  INHALER. 

Our  climate,  in  modern  times,  seems  to  be  adapted 
to  the  development  of  diseases  of  the  mucous  membrane 
of  the  air  passages.  The  dust  of  the  cities,  the  sporules 
of  the  flora  and  grasses  of  the  country,  acute  colds,  the 


DOUCHE  AND  INHALER  221 

employments  of  baking,  milling,  factor}  operations, 
threshing,  traveling  on  the  railroad,  and  ,not  least,  bad 
ventilation,  all  tend  to  the  development  of  local  disea 
In  the  majority  of  cases  it  is  but  a  local  disease;  in  a  feu- 
it  arises  from  a  low  vitality  of  the  system,  or  an  actual 
constitutional  disease;  but  the  nasal  cavity,  subject  to 
such  noxious  influences  as  above  enumerated,  followed 
bv  inattention  to  the  acute  stage  on  catching  cold,  is  left 
in  a  semi-inflamed  condition,  and  this  is  the  chronic  ca- 
tarrh; and  each  successive  cold  and  exposure  to  irritat- 
ing influences  but  adds  to  the  inflammation,  and  leaves 
an  additional  chronic  condition.  A  small  percentage  of 
people  catching  colds  have  vitality  to  throw  off  the  local 
effects  with  the  restoration  of  the  constitutional  disturb- 
ance; but  the  majority,  after  such  attacks,  experience 
insidious  effects,  and  a  continuance  of  these  conditions 
break  down  the  health. 

It  is  not  strange  that  the  nasal  organ  should  suffer 
in  the  new  order  of  things  in  a  forced  civilization — suf- 
fer in  its  office  of  purifying  the  atmosphere  under  such 
modes  of  living.  The  too  common  opinion  that  catarrh 
is  a  disease  of  the  blood,  and  that  it  can  be  cured  by  con- 
stitutional remedies,  must  be  given  up.  The  tone  of  the 
system,  it  is  true,  will  make  some  difference  in  the  power 
of  resistance  of  the  effects,  and  this,  even,  can  be  heieht- 
ened  by  some  internal  medicines,  and  people  will  recover 
from  colds  without  the  chronic  effects,  but  nasal  and 
throat  catarrh  affect  the  most  robust,  as  every  physician 
knows  who  has  treated  this  disease  to  any  extent.  The 
specialty  of  the  diseases  of  the  throat  and  nose  has  im- 
proved the  means  of  treating  these  parts,  both  in  instru- 
ments for  examination  and  treatment  as  well  as  in  the 
remedies  for  medication.  The  paraphernalia  oi  the 
physician  in  a  well  equipped  office  is  very  satisfactory 
or' office  treatment,  but  the  instruments  are  expensive 


EAZEN'S  NEW  FINDINGS 

and  must  be  handled  by  experts.  The  expectation  of 
having  patients  attend  long  enough  and  often  enough  to 
be  cured,  is  not  realized  in  the  majority  of  cases,  and 
the  consequence  is,  these  troubles  have  the  reputation  of 
being    incurable. 

The  greatest  necessity  in  the  case  is  to  secure  an 
apparatus  sufficiently  simple,  agreeable  and  effective; 
one  that  can  be  easily  handled  and  daily  applied  by  the 
patient  at  home.  Frequent  washings  and  medication  are 
necessary,  and  when  this  is  done  under  proper  direction 
with  the  remedies,  of  which  we  have  abundance,  disease 
can  be  averted  ,and  disease  already  established  can,  in  a 


Fig.   i. 

An  Apparatus  for  the  Treatment  of  the  Mucous  Membrane 
oi  the  Air  Chambers.  * 


majority  of  cases  be  effectually  cured.  Neglect  of  the 
principles  which  cause  disease  in  any  part  of  the  system, 
viz:  allowing  foreign  accumulations  to  remain  in  the 
parts  and  neglecting  the  proper  cure  of  the  acute  stages, 
will  inevitably  develop  the  chronic  forms,  which  will 
result  in  future  suffering  or  will  open  the  avenues  upon 


This  Instrument  can  be  had  of  A.  W.  Hazen,  Des  Moines,  Iowa. 


DnrcilK  AND  ixiiai.kr 


which  the  patient  makes  his  exit  out  of  the  world.  Why 
catarrhal  troubles  should  be  so  neglected,  and  why  inat- 
tention to  them  should  be  so  universal,  with  the  idea 
it  is  "only  a  cold", or  that  "they  will  outgrow  it,"  seems 
strange,  unless  it  be  because  of  the  generally  disagreeable 
methods  practiced. 


Fig.  2. 
Douche  and  Inhaler. 


In  1S80  the  writer  devised  a  douche  and  inhaler  and 
an  account  of  it  was  published  in  the  transactions  of  the 
Iowa  State  Society,  1881.  The  process  of  douching 
by  this  instrument,  is  founded  upon  the  fact  that  by 
blowing  upon  a  body  of  fluid  in  an  air-tight  chamber,  it 
can  be  made  to  rise  in  a  tube  thrust  in  it,  and  flow  out 
through  it  into  the  nose  when  directed  there,  and  in  this 
act  of  blowing,  the  palate  presses  upon  the  posterior 
pharnyx,  and  forms  a  floor,  and  will  sustain  this  body 
of  fluid  as  it  rises  to  the  roof  of  the  nasal  cavity.  It  the 
head  is  thrown  well  back,  the  cavity  will  hold  about  an 
ounce.  The  fluid  thus  acted  upon,  floods  the  posterior 
and  superior  parts  of  the  cavity  and  on  removing  the  in- 


•.'•21  KAZEN'S  NEW  FINDINGS 

strumenl  from  the  nose  and  mouth,  it  is  in  the  best  pos- 
sible position  to  be  thrown  into  the  anterior  parts,  by 
bringing  the  head  forward,  and  at  the  same  time  exhal- 
ing forcibly. 

The  safety  in  this  douche  is  in  the  fact  there  is  no 
pressure  to  carry  the  fluid  into  the  Eustachian  tube, 
and  as  the  tube  remains  closed  only  as  the  act  of  swal- 
lowing is  performed,  and  that  while  performing  the  act 
of  douching,  they  cannot  swallow,  it  renders  it  per- 
fectly safe.  From  this  fact  it  allows,  also,  medication 
of  such  strength,  that  it  will  be  of  more  effect  than  the 
solutions  that  must  be  used  in  the  ether  forms  of  douche. 
The  Sphenoid  sinus  is  also  medicated  quite  effectually 
by  this  douche  and  the  interstices  about  this  cavity  are 
cleaned  by  it.  The  instrument  is  made  of  glass  and  is 
easily  cleaned.  This  instrument  has  now  been  in  use 
for  over  twenty  years  in  the  writer's  practice,  and  no 
inflammation  of  the  Eustachian  tube  produced  by  its 
use  has  come  to  his  knowledge. 

DIRECTIONS  FOR  USE. 

Showing  position  of  head  in  act  of  douching  by  this  method, 
and  the  internal  parts  involved,  i  b,  turbinated  bones:  d,  sphenoid 
cavity;  e,  eustachian  orifice;  c,  palate  closing  upper  pharnyx  from 
lower,  upon  the  act  of  blowing  upon  the  mouth-piece  of  instrument; 
a,  level  of  fluild  obtained  by  the  use  of  douche. 

FIRST.     USE  AS  A  DOUCHE  (FIG.  3.) 

Directions. — Remove  cork  (c,  Fig.  2),  and  pour  the  flluid  to 
be  douched  into  leg,  A;  the  replace  cork;  place  forefinger  on  opening 
at  E,  other  fingers  aroynd  B,  and  thumb  around  A;  the  introduce 
end  of  flexible  tube.,  F,  into  nostril,  straight  back,  allowing  it  to 
rest  on  the  floor  of  the  nose;  then  put  the  mouth-piece  G,  into  the 
mouth  (having  taken  a  long  breath);  blow  steadily,  inclining  the 
head  backward,  whereupon  the  fluid  will  ascend  through  the  head 
backward,  whereupon  the  fluid  will  ascend  through  the  inner  tube 
in  B,  and  flow  into  the  nasal  cavity.      Before  a  full  breath  can  be 


DOUCHE  AND  [NHALER 


exhausted,  the  fluid  will  overflow  out  of  the  nose,  or  a  lignal  will 
be  given  by  the  air  entering  the  tube  at  the  bottom  of  B,  when  the 

instrument  may  be  removed;  and  if  the  checks  arc  swelled  out  bj 

inflation  of  air,  the  palate  will  continue  to  form  a  floor  and  hold 
the  fluid  in  the  nasal  capacity.  After  retaining  the  fluid  for  a 
few  seconds,  and  turning  the  head  from  side  to  side,  on  bringing 
the  head  forward  the  fluid  will  run  out  of  the  nostrils  over  the 
floor  of  the  the  nose. 


Fig.  '3. 
ANATOMICAL. 


When  it  is  desirable  to  medicate  the  turbinated  bones  (t  b). 
anteriorly,  this  can  be  effected  by  coming  forward  quickly  and 
exhaling  from  the  lungs  suddenly,  thus  blowing  the  medicine  well 
into  the  front. 

N.  B. — A  full  breath  must  be  taken  at  the  start,  and  if  a  pre 
is  not  kept  up  by  a  gentle  blowing,  the  palate  will  not   maintain 
its    place.     If    taking    a    breath    is    attempted    during    the    pr 
fluid   will   fall   upon   the  larnyx.   which   will   cause  cough 


226 


HA  ZEN'S  NEW  FINDINGS 


SECOND.     STEAM  INHALATION     FIG.  4). 

Directions. — Put   into   leg     A,   the 
medicine  to  be  inhaled. 

(a)  For  treatment  of  the  Nasal 
Cavity  Only.. — Take  out  the  inner 
P  tube  in  B,  and  put  the  end  of  the 
flexible  tube,  F,  into  cork,  D.  with 
the  flexible  tube  outside,  and  place 
the  other  end  into  the  nostril,  with 
the  forefinger  on  E,  and  blow  into 
the  mouth-piece.  By  this  method 
the  nasal  cavity  can  be  treated 
without  medicating  the  throat  or 
lungs. 
Fig.  4 

(b)  For  Medicating  the  Whole  Mucous  Membrane  of  the  Brionchal 
Tubes,  Throat,  and  Nose  (Fig.  4). — Take  off  the  flexible  tube; 
put  medicine  into  leg,  A;  put  the  forefinger  over  vent,  E;  draw 
steadily  at  the  mouthpiece,  G  (a  piece  of  cotton  wadding  or  sponge 
can  be  put  under  cork,  C,  but  generally  it  is  not  needed).  The 
vapor  is  inhaled  directly  into  the  lungs  and  exhaled  through  the 
nose.  The  fluid  in  the  bottom  of  the  U  tube  can  be  kept  hot  by 
immersing  the  U   tube   midway  into  a  cup  of  hot  water  or  sand. 

THIRD.     DRY  VAPOR  INHALATION  (FIG.  5). 


Directions. — Put  medicine  for 
vaporing  on  cotton  as  at  H,  Fig.  5 

(a)  For  treatment  of  the  Nasal 
Cavity  Only. — Put  end  of  flexible 
tube,  F,  into  the  nostril,  forefinger 
on  E,  and  blow. 

(b)  For  Medicating  the  Whole 
Mucous  Membrane  of  the  Bronch- 
ial Tubes,  Throat,  and  Nose. — 
Take  off  the  flexible  tube,  and 
draw  into  the  lungs  through  the 
mouth-piece;  and  exhale  through 
the  nose. 

X.  B. — The  temperature  of  the 
air  brought  to  the  mucous  mem- 


Fig.  5. 


DOUCHE  AND  INHALER 


brane  can   be  raised   and   the   medicine   mure  readily   vaporized   by 
putting  the  U  tube  into  hot  water  or  sand,  as  in   Fig.    1. 

FOURTH.     AMMONIA  INHALATION   (FIG.  6  . 

Directions. — To    leg,    B,    (Fig.    2),    a    small    bulb.    I  .          firmly 
attached — a   rcceptable  for   the   Muriatic   Acid.      In    this,   first    put 

a     small     amount    of     absorbent     cot- 
ton,      loosely        packed,      on        which 
drop    three    drops    of    the    acid.      Put 
the    Ammonia    (about    20    drops)    and 
two   teaspoonfuls  of   water   in   b< 
of    U    tube.     Then    add    mcdicim 
required.     Then     place     forefinger     on 
end    of    tube    at     D.      Upon    inhaling 
at  the   mouth-piece,  G,   nascent    Mur- 
iate   of    Ammonia    will    be    generously 
produced.     To  prevent  the   Ammonia 
from    being    inhaled    before    the    acid 
comes    in    combination    with    it,    place 
a    piece   of   moist   sponge    under   cork, 

FIFTH.     TO  USE  IN  THE  EXTERNAL  EAR    FIG.  7  . 


Direction  a  --To 

douche  the  externa!  car, 
fill  the  instrument;  put 
the  tube,  F.  into  the 
meatus,  and  blow  the 
fluid  into  ear  by  blow- 
ing on  the  mouth-piece, 
:id  holds  a  small  \  es- 
sel  under  the 

hi     case    "!     earache 

7  :         \  ■■  ke    oul 

cork.    D .     I  with 

ilisidc    tube  and  the  I 
ible    tube;    take 

ible  tube,  and  take  oul 

■HRB11      the  long   glass    tube:    re- 


Fig.  7 


2  I  i 


HAZEN'3  NEW  FINDINGS 


place  the  cork.  Now  put  the  glass  end  of  flexible  tube,  F,  into 
cork,  and  then  put  the  straight  end  of  the  long  glass  tube  on  the 
other  end  of  flexible  tube,  and  it  is  arranged  as  in  Fig.  7. 
Put  two  teaspoonfuls  of  hot  water  in  U  tube,  then  put  U  tube  into 
hot  water  or  sand;  place  the  bent  edge  of  glass  tube  into  the  ear, 
with  forefinger  on  E,  and  blow  gently  at  the  mouth-piece;  the 
warm  vapor  should  be  blown  directly  onto  the  drum,  and  it  will 
almost  invariably  relieve  the  pain. 

SIXTH.     POWDER  BLOWER— INHALATION   (FIG.  9). 


Directions.  —  Take 
out  cork  ,D,  with  glass 
tube  and  flexible  tube. 
Put  powder  on  paper, 
and  push  it  with  a 
knife,  as  shown  in 
Fig.  8,  into  end  of 
tube,  I;  then  by  plac- 
ing the  end  of  the  tube 
Fi§-  8-  thus    loaded     into    ear 

or  nose,  as  required,  and  the  end,  F,  into  the  mouth,  the  powder 
can  be  blown  into  the  part.  A  second  person  or  an  airbulb  is  re- 
quired when  the  nasal  cavity  is  medicated  from  behind  the  palate. 
The  bent  end  is  introduced  into  the  mouth  and  the  medicine  is 
thrown  into  the  nose  from  behind  the  palate. 

Caution. — The  temperature  of  fluids  for  douching  should  be 
above  blood  heat.  In  all  these  methods,  in  order  to  make  the 
instrument  work  satisfactorily,  it  is  necessary  that  the  corks  be 
air-tight.  Patients  using  the  instrument  in  the  winter  should 
not  go  into  the  open  air  for  half  an  hour. 


DIRECTIONS  FOR  CLEANING. 


Empty  the  instrument  of  cotton,  etc.;  replace  corks;  place  the 
end,  F,  into  water,  a,nd  draw  at  the  mouth-piece  until  the  instru- 
ment is  nearly  full;  then  shake,  and  blow  out  the  fluid,  reversing  its 
course. 


DOUCHING  OF  CHILDKKN 


DOUCHING  OF  CHILDREN. 

It  cannot  be  expected  that  children  under  ten  years 
of  age  will  be  able  to  douche  the  nose.  For  those  of 
over  four  years  of  age,  I  fill  the  common  vulcanized 
syringe  with  the  fluid  to  be  injected,  and  put  the  child 
in  front  of  me,  with  his  back  against  me  and  holding 
the  face  steadily  by  placing  my  hand  under  the  chin,  and 
stretching  his  neck  a  little,  cause  him  to  swell  the  cheeks, 
when  I  place  the  nozzle  in  one  nostril,  directing  the 
stream  back  over  the  floor  of  the  nose  with  some  consid- 
erable force,  when  it  will  return  out  at  the  opposite  side 
in  a  stream  into  the  spittoon  placed  in  front.  If  the 
child  will  keep  his  cheeks  swelled  out,  no  fluid  will  pass 
into  the  throat,  and  the  cavity  is  fairly  medicated.  To 
medicate  the  region  of  the  Eustachian  tube  on  the  oppo- 
site side  as  well,  the  injections  should  be  given  in  a  simi- 
lar manner  on  the  opposite  side. 

The  writer  regards  douching  of  the  nose  with  warm 
solutions,  much  more  favorably  than  sprays.  The  lat- 
ter in  the  hands  of  the  skilled  operator  may  be  effectual 
in  cleaning  the  interstices  of  the  cavity  of  the  nose,  but 
the  spraying  is  a  cold  process  and  all  the  erectile  tissues 
of  the  cavity  are  excited  and  catheterization  is  more  diffi- 
cult and  painful  afterward.  The  douching  by  the  in- 
strument above  described  is  directed  by  the  author,  to 
be  done  before  visiting  the  office,  or  before  his  visit  at 
the  home,  and  the  locality  is  generally  clean,  and  all  ex- 
citement will  have  subsided.  More  thorough  cleaning 
is  sometimes  necessary,  but  not  often. 

The  writer  has  repeatedly  cured  acute  cases  of  otitis 
media  purulenta  by  this  method  when,  in  the  light  of 
the  present  day,  many  surgeons  would  decide  on  an- 
trectomy, and  in  many  cases  this  had  already  been  ad- 
vised.    He  believes  that  when  the  tympanum  is  relieved 


280  IIAZEXS  NEW  FINDINGS 

of  the  pressure  of  fluids,  by  giving  vent  through  the  Eu- 
stachian tube,  the  contents  of  the  mastoid  antrum  can 
be,  and  are  drained  from  this  cavity;  that  in  many 
natural  positions  of  the  head,  when  in  this  condition, 
fluid  escapes  into  the  tympanum  and  out  by  the  Eusta- 
chian tube.  At  least  the  products  of  inflammation  es- 
cape or  are  absorbed,  for  mastoiditis  gets  well  without 
opening  the  cells. 

A   few  cases  are  herewith  appended: 

Case  1.  Miss  E.  A.,  young  lady  of  18  years,  was  brought  to 
my  office  by  her  attending  physician,  November  19,  1S9 — .  She 
was  pale  and  aeneanemic,  having  lost  fifteen  pounds  since  becoming 
sick.  She  had  to  be  supported  in  walking,  becoming  dizzy  when 
on  her  feet.  She  held  her  head  to  one  side.  Behind  the  right  ear, 
over  the  mastoid,  there  was  a  swelling  that  was  red  and  fluctuating, 
and  caused  the  ear  to  stand  out  at  nearly  right  angles  to  the  bone. 
She  had  the  following  history.  On  the  27th  of  October,  after  riding 
about  two  miles  she  had  a  sore  throat,  and  in  three  weeks  had 
earache.  The  drum  broke  the  next  day,  since  whick  time  she  had 
been  treated  with  tonics,  narcotics,  Politzerization,  fomentations 
and  syringing  the  auditory  meatus.  The  ear  remained  closed, 
however,  and  the  heavy  dragging  feeling  was  not  relieved. 

I  at  once  introduced  the  catheter  and  injected  the  Eustachian 
tube  with  solution  of  Boracic  acid  ;afterwards  blew  out  with  air 
bag  and  catheter  which  opened  up  the  ear.  After  blowing  in  the 
powder  of  the  acid  in  the  tympanum,  she  went  to  her  boarding 
place.  The  next  morning  at  8:30  I  found  that  she  had  had  the  best 
night's  rest  since  she  became  sick.  Swelling  behind  ear  had  gone 
down  two-thirds.  She  was  eating  her  breakfast  and  feeling  in 
good  spirits.  Injected  as  before,  the  solution  penetrated  well  up 
into  the  tube  and  opened  the  cavity.  Left  douche  to  be  used 
twice  a  day  with  solution  of  Potass  cholras  and  Borax  each  four 
and  a  half  grains  to  the  ounce  of  water.  To  syringe  ear  with 
pippette,  as  described  in  these  pages,  and  then  blow  in  the  meatus 
powder  of  Boric  acid.  This  case  was  thus  treated  daily  for  seven- 
teen days  at  which  time  the  discharge  was  stopped,  hearing  good, 
and  improved  in  general  health.  No  tonics,  or  narcotics  were 
given. 

Case  2.  E.  R.,  December  6,  1894,  a  girl  of  13  years  found 
lying  in  bed  and  very  weak.      For  ten  days  had  had  pain  in  right 


DOrCIUNd  OF  CHILDREN  281 

ear,  but  was  relieved  after  three  day's  suffering,  to  a  consider., 
extent,  by  breaking  of  the  drum  and  a  discharge  from  the  ear. 
The  former  physician  had  given  her  internal  medicines  but  made 
no  application  to  the  ear.  She  was  SO  reduced  in  strength  that 
she  had  to  be  propped  up  with  pillows, while  introducing  the  catheter. 
I  treated  her  as  in  the  former  case  six  days  in  n  when 

seemed  perfectly  well,  and  though  she  remained  in  bed  two  w< 
thereafter   under   the   care  of  another   physician    for    malaria   or   la 
grippe,  her  ear  troubled  her  no  more. 

Case  3.      E.    R.    T.,    a    young    man    of   twenty    years,    a    ph 
rapher  came   to   my  office   December   17,    1894.     Two  days   before 
his  ear  commenced  to  pain  from  a  severe  cold  he  had  caught.      He- 
was  reduced  in  strength  and  was  suffering  intensely.      Found  drum 
bulging   which    I    incised    and    injected    as    in    other   cases,    blow 
air  in   afterwards   through   the  catheter,   which   opened   up   the 
and  made  it  lighter.      Up  to  Christmas  (eight  days)  ear  continued 
to  discharge  from  the    meatus,    but    then    ceased,    but    the    sound 
on  blowing  through  the  catheter,  was  persistent,  and  I  treated  him 
after  this  time  although  he  returned  to  his  work.     The  treatments 
were   now  at  longer   intervals,     and     I   discharged   him   cured    with 
good  ear  on  the  6th  of  March. 

Case  4.  Mrs.  W.,  a  middle  aged  lady.  Called  to  her 
at  9  o'clock  in  the  evening  of  April  19,  1893.  She  had  had  an 
attack  of  gastritis  and  was  under  one  of  our  best  physicians.  She 
claimed  that  she  had  no  nasal  catarrh,  but  acknowledged  that  there 
was  some  dropping  down  the  posterior  pharynx  and  some  cough. 
She  was  having  earache  in  right  ear  and  was  applying  hot  fomenta- 
tions and  douching  the  ear.  The  external  ear  was  so  swollen  that 
I  could  not  get  a  view  of  the  drum,  but  there  was  no  discharge. 
I  treated  this  case  with  the  air  bath  with  the  catheter,  which  g 
immediate  relief,  and  in  the  morning  injected  the  boracic  acid  so- 
lution. Ten  treatments  in  this  case  gave  permanent  cure  and  a 
good  ear. 

Case  5.  R.  B.  S.,  May,  1S99.  Farmer,  age  31.  Called  in 
consultation  with  one  of  the  first  surgeons  at  Mercy  Hospital. 
Had  had  severe  inflammation  and  earache  for  four  weeks  in  left 
ear.      Pain  mostly  behind  ear,  far  back;   tender  on  W  I 

so  much  debilitated  that  the  surgeon  deemed   it   unsafe  to  und 
an  operation.      While  sitting   up   in   bed    I    introduced   the   call; 
and    injected    the    Eustachian    tube    with    Boracic    acid    Boluti 
Douching  of  the   nose  was   then  directed    to   be   given    with   the   I 
tube  twice  a  day,  two  doses  at  a  sitting.     The  next  morning  found 
that  the  patient  had  had  the  best  night's  rest  than  for  many  night 


282  IIAZEXS  NEW  FINDINGS 

Repeated  the  treatment  daily,  and  washed  out  the  external  meatus 
as  well,  dried  with  swab  and  blew  powdered  Boracic  acid.  In  a 
few  days  the  Eustachian  tube  became  pervious  and  on  injections 
there  would  be  a  few  drops  of  fluid  in  the  external  meatus.  The 
discharge  which  was  ropy  at  first,  lost  this  quality  and  in  fifteen 
davs  he  was  sufficiently  recovered  to  be  able  to  attend  at  the  office, 
lie.  however,  had  a  relapse  by  catching  cold  and  his  surgeon  per- 
formed  the  Mastoid  operation. 


INDEX 


Page 

Accommodation     100, 

Abduction      _ r,7 

Adduction     1 7 5 

Adjustment — Stevens.      Neuropathic    tendency 89 

American    Ophthalmological    Society    Meeting 

Amplitude    of    convergence »;  j 

Ametropia,    etiology     7  7 

Ammonia  Inhaler 227 

Asthenopia     13,     1!'.    1-7 

Accommodative,    Anamolies    of 17 

Accommodative,    Bader     ::  1 

Apparent     19,      32 

Associated   with  muscular 17 

Congenital    predisposition    explained 19 

Bonders     17. 

Noyes     _ )  ■'• .      17 

Oliver,     Philology      7  > 

Early    history    of    .         1  9 

Philology     of      

Philology    of     --      1:7 

Proceeds     from     Fatigue 21 

Roosa    

Rueta,    theory    of 

Se-hmidt-Rumplcr     71 

Stellwag     - 

True    and    false    H 

V<  'ii     Graefe     Is 

Wells  J.  Soelberg  

Treatment     

Althoff,    Dr 

Author    1  » :;-    1  •"• 4 

Bader,    Charles    '•  - 

Delafield,    Dr 

Derby,    Dr 

Donders,     Prof '  '■' 

Dyer,     Dr 

Electricity    in     

Landolt,    Dr 


Noyes,   Dr 


284  [NDEX 

Page 
Asthenopia— Treatment— Continued. 

<  Hiver,     l  >r 78,  84 

Roosa,    I  >r,    75 

Sands,     I  >r.     73,  27 

Schmidt-Rumpler    ~- 

Steven.s,  Dr.    . l  37,  96 

wells,    j.    Soelberg ......  41 

Williams,    1  >r 30 

Causes  of — 

i  [eterophoria     79 

Donders,     Prof -- 20 

Noyes,    l  »r 15,  I  ~ 

Oliver 7 s 

Roosa      71 

Stellwag     36 

Muscular — 

Landolt,     Dr 55,  66 

Noyes,   Dr 27,    46.    48,  IT 

Oliver,     Dr sl 

Roosa,    Di\    "4 

Stellwag,    Prof 36 

Vt  .n    Graef e    21 

Wells,    J.    Soelberg    ~ 39 

Retinarhyperemia — 

Stellwag-       36 

Wells     39 

Bader,    Charles    31 

Balance  and   Equilibrium,   Author 131 

Balance   simple,    Howe    112 

Balance   compound,    Howe    11-1 

Cases,    Ophthalmological    191 

Cases,     Otological     230 

Convergence,    Author    163,  203 

Diagnosis,    Landolt    66 

Effect  of  glasses 53 

Treatment,     Landolt     68 

Not   in   other  animals    57 

Relation  to  accommodation    108 

Non-paralytic.      Landolt     58 

Insufficiency     of — Landolt 63 

Catheter-Eustachian     213 

Vs.    Poleitzer-bag     215 

Convergence — 

Author      163,  203 

Classification — 

Author     148 

Cycloduction — 

Author     178 


INDEX 

Cyclophoria     

Author      117 

Clinoscope     :•  1 

Decentering  of   Lenses 

Declination,    treatment     

Declination,    measurement    :•  i 

Delafield,    I  »r.    E 23,  24 

Derby,   Dr.    :\ 

Deviation     119 

Diagnosing,   Author    161 

Divergence,    non-paralytic.      Landolt 58,  ('-i 

Donders,    Prof 17 

Douching,     Otological     220 

Douching  children    229 

1  >ry     Vapor — Inhalation     

Duction     

I  >yer,   Dr 

Ear-ache     227 

Esophoria,    Author    — — l  96 

Equilibrium     81,     131,     133,  L39 

Eukenises 1  09,  L35 

Examination — Methods — Howe     106 

Extra    Ocular    Muscles 11".  11-' 

pupils   school    1  y ■"■ 

Exophoria    Author    __ .. L96 

Eye  strain   13,  78,   11".   117.  127 

Find/ngs,    Author Ill 

Fusing    faculty    178 

Fusing    power,     Howe     

Glass-fitting    craze     179 

Maddox    Rod,    Landolt — 

Mental,    Author    153 

Meter   angle,    Nagel . — 

Migraine.      Oliver    s  7 

Moore,    Wm.    D.,    Translator 17 

Muscle    Examination,     Howe    L06 

Muscle    Balance,    Howe L09 

Muscular   Imbalance — 

Weakness     ' ' 

Trouble     16 

Habitudeo    vises    19 

l  [ackley,  « Jharles  E.,  M.   I » 

Heterophoria    "'•'•    s '  • 

Heterophoria     latenl     82,  L37 

Howe,  Lucien,  M.  D 

Heterocykinesis,     Howe     1,n 

Heterophoria,    Author    ••* 

compound,     Howe     '-1 

simple,    i  [owe    '  -'" 

Hypermetropia,    discovery   of    ' s 

Hyperphoria,  Author  '  ,,: 


236  INDEX 

Page 

[ntroductlon     

Enquiries     14 

Insufficiencies     21,  50 

Bodrr     32 

Donders,    Prof 2  1 

1 1 <  >\ve     13 

Latent     37 

Landolt    .",,    63,  65 

Schmidt- Rumpler    71 

Roosa     74 

Imbalance,    result   of   Eye-strain 110 

Imbalance,   ocular  muscle    109 

Imbalance,    simple,    Howe Ill 

[mbalance,  compound,  Howe   114 

Intra-ocular   muscles __ Ill 

Kinothalmoscope.       Landolt     68 

Kratometer     158,  188 

Landolt,    E.    M.    D.    __ 53 

Lenses,  effect  of 163,  166 

Maddox     Rod,     Landolt     67 

Mental,     Author    _. __ 153 

Meter  angle,    Nagel    169 

Migraine,   Oliver    87 

Moore,  Wm.  D.,  Translator    .- —  17 

Muscle   Examination,    Howe — 106 

Muscle   Balance,    Howe    -- .  .  109 

Muscular   Imbalance    109 

Muscular   Weakness    44 

Muscular    Troubles 4  6 

Nagel' s  M.   a 169 

Nature    aids     __ „ 143 

Nerve    storms    79 

Neurasthenia     79 

Xeuhasthenia,    Author    __.  .  .  149 

Neuralgia      __ __ 149 

Nomenclature    of    Stevens     --.  91 

Noyes,    Dr.    H.    D 23,    27,    43,  136 

Ocular   Trapeze    209 

Oliver,    Dr.    Chas.    A 7  7 

Ophthalmo    dynamometer     66 

Ophthalmo    dynamameter,    Modification __ 203 

Operation,   Bader    33 

Orthoptic    treatment    138 

Otology     207 

Otitis    Media    207 

Paretic    Heterophoria    80 

Philology   of   Asthenopia    127,128 

Phoria,     Stevens     _. 91 

Phorometer,    Stevens     .  .__ 93 

Power    balance    of — Howe    _. 107 

Powder   blower    228 


[NDEX 

Page 

Preface     

Prism — Crutch     v  ( 

Prisms — Howe l  l ::,      i  i  1 

Prism,   effect  of   lenses ;,  I , 

Pism  efficiency   of — not   realized 

Principles  of  Author j  \  _• 

Ranney     1 ::  7 

Reading  distance  test,  Author 1  r,:: 

Red  glass,  Landolt 1,7 

Reflex      go,      1  1  8 

Reflexes     1 ;,  1 

Regional    Exclusion     :,  s 

Roosa,  D.  B.  St.  John,  Dr :;:,. 

Roosa,    Dr.,    Ear    _. 210 

Ruete   &   Bohm    Is 

Sands,    Dr 26 

Screen    test    :;  j 

Schmidt-Rumpler,   Dr 71 

Stevens,    Dr.    Geo.    T 89,    137 

Stellwag,   Carl,   M.   D :::, 

Strabismus,    Wells    (0 

Strabismus,    Landolt    ."7 

Strabismus,    Non-paralytic    divergent 58,      »'•  1 

Strabismus,    Causes,    Landolt    

Treatment,    Landolt    _. 60 

Stereoscopes,    Howe     1  "7 

Strength    of   muscles 135 

Strength   of   Muscles,    Author    . 163 

Steam   Inhalation    

Spasms  of  Accommodation    17.      19 

Spastic    heterophoria     80 

Suppression   of   false   images 95, 

Tests — 

Classification,    Howe    103 

Convergence.  Author   163,   203,    166 

Reading  distance    

Muscular  strength    IT" 

Noyes     I  •'• .     50 

Tendon    Insertions    '.'1 

Torson    90,    108,    LIS 

Tropometer     90 

Torticollis     115 

Stevens     

Tenotomy — 

Landolt    

Stevens     1  ■".  7 

Trapeze  Ocular   

Tympanum,    cleaning 

Verticals,   Author    17  7 

Von  Corion,  Carl  Stellwag  


INI)  1 0  X 

Page 

Von   Graefe    18 

Wells  J.  Soelberg  39 

Weakness    of   muscles,    Stevens    94,  136 

Williams,    I>r.,   of  Boston 25 

Williams.   Dr.,  of  Cincinnati 25 


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